Single Mothers Group Interest Form
Please complete the form below, and our group facilitator will contact you! If you would like to speak with someone sooner, please give us a call (516-785-0323). Thank you!
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Phone Number
*
Format: (000) 000-0000.
Are you currently a patient at South Shore Counseling?
*
Please Select
Yes
No
If not, are you currently working with an individual therapist elsewhere?
*
Please Select
Yes
No
The group will meet Saturdays from 11 AM to 12 PM in Massapequa on an ongoing basis. The start date is pending. Does this work for you?
*
Please Select
Yes
No
Insurance information, including name and policy number
*
Are you currently a single mother?
*
Please Select
Yes
No
How old are your child(ren)?
*
Have you ever participated in a support group before?
*
Please Select
Yes
No
What are you hoping to gain from this group?
*
In which areas of your life do you most need support right now?
*
Do you have any questions, concerns, or worries about participating in a therapy group?
*
Is there anything you think would help us support you during group?
*
Submit
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