Group Interest Registration Form

Registrations Open · 2026–2027 Cohort

LGBTQ+ Support Group
Interest & Registration

Complete this short form to reserve your spot in Dr. Jordan Williams’ affirming group therapy program for adults in Central Arkansas. In-person only — limited to 6–10 members.

👤 In-person only 📍 Little Rock, AR 📅 Twice monthly · 2026–27 👥 6–10 members max 🔒 Confidential 👤 Adults 18+ only

ⓘ This group meets in person only at 7509 Cantrell Rd, Suite 221, Little Rock — no virtual or hybrid option is available. Submitting this form is not a commitment. We’ll contact you with scheduling details once enough interest is confirmed.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have active health insurance?

What insurance do you have?

ex: Blue Cross Blue Shield

Would you want to know what you'd pay per session?

To verify your insurance benefits and confirm your session cost, please upload a clear photo of the front and back of your insurance card.

Front

Back

Check all the days and times that would work for you to meet.

Rows	8am – 11am	11am – 2pm	2pm – 5pm	5pm – 8pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Tell us what you hope to get out of this group.

By submitting this form, you consent to being contacted by Your Choice Mental Health Therapy by phone, text, or email for the purpose of providing information about the LGBTQ+ Support Group program. Standard message and data rates may apply. You may withdraw consent at any time by contacting us at support@yourchoicemht.com.