Clone of Trans & Gender Exploration Group

1
Full Name* This field is required.
First Name
Last Name
2
Preferred Contact Method* This field is required.
Phone
Email
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Email * This field is required.
example@example.com
5
Pronouns
6
Have you been in individual therapy before?* This field is required.
YESNO
7
Have you participated in group therapy before* This field is required.
YESNO
8
Are you currently a patient at PMA Health* This field is required.
YESNO
9
Briefly describe describe your desire and interest in our group* This field is required.
10
What do you hope to gain from attending the group? What are your goals* This field is required.
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Small
Ok
Ok
11
This group will be a commitment, meeting every Thursday (virtually) at 7pm . Is there anything that might get in the way of you consistently attending the group* This field is required.
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Ok
12
Do you have any accessibility or accommodation needs?If so please share
13
How did you hear about this group? (Referral/Source)
14
I consent to be contacted by a group facilitator regarding my interest in the process group.* This field is required.
Should be Empty: