Group Therapy Application

Closet Therapy with Dina

Emotional Strength Training Group Therapy Application
"This is a curated group therapy experience. Not all applicants will be accepted. This process helps ensure a safe, supportive, and aligned group environment."
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your preferred method of contact?*

EmailText Message
Tshirt Size? (women's cut)*
Please describe your CURRENT experience.
1. What is bringing you to this experience at this time?
(Briefly describe what you are currently navigating emotionally or mentally.)
How do you typically respond when emotions feel overwhelming?*

I shut down, withdraw, or check-outI become reactive, overly emotional or outwardly overwhelmedI avoid or distract myselfI can stay present but it feels difficultOther
Briefly describe if you checked "Other"
What are you hoping to gain from participating in this group?
(Please be as honest and specific as possible.)
Therapy History and Readiness Assessment
Have you ever participated in individual/group therapy?

YesNo
If yes, what was helpful or not helpful about the experience?
On a scale of 1-10, How comfortable are you with being emotionally open in a group setting? (1=very uncomfortable, 10=very comfortable)*
(There is no wrong answer:) )
This group consists of both emotional education and processing and light to moderate movement. (Yoga, pilates, walking etc..) Are you physically able to perform light to moderate movement?*

YesNoUnsure
Current Mental Health Status

There is no wrong answer here. Please be honest.
Are you currently experiencing any of the following? Check all that apply.*

AnxietyDepressionPanic AttacksTrauma-Related SymptomsHigh Stress or OverwhelmNone of the Above
Are you experiencing any of the following? Check all that apply.*

Suicidal ThoughtsSubstance Abuse ConcernsRecent Psychiatric HospitalizationSevere emotional distress that feels unmanageableNone of the Above
(If any of the above are selected, we may discuss additional support options to ensure you receive the appropriate level of care.)
Group Expectations
This experience includes:
- Active participation in a small group setting
- Emotional processing (not just discussion)
- Respect for confidentiality and shared space
- A movement-based component in each session
Are you willing to actively participate and engage in both the emotional and movement portions of the group?

YesNo
Are you willing to commit to all 5 sessions?

YesNo
Program Investment
Early Bird: $447
Regular Rate: $597

Payment Plan Options Available.
(Superbills are available upon request for possible out-of-network reimbursement.)
Are you prepared to invest if your application is accepted?

YesNo
Final Thoughts
Are there any additional things you would like me to know as I review your application?
Next Steps

After reviewing your application, you MAY be invited to a brief consultation to ensure this experience is the right fit for you. This group is intentionally limited to maintain a safe and supportive environment. Thank you for your consideration.
Signature
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Closet Therapy with Dina

Please describe your CURRENT experience.

Therapy History and Readiness Assessment

Current Mental Health Status

Group Expectations

Program Investment

Final Thoughts

Next Steps