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Support or Therapy Group Interest Form
Please fill out this form to let us know more about what type of group you (or your child/teen) is interested in joining. If you are seeking a group for more than one person, please fill this form out for each person interested. One of our therapists will follow up within 48 hours.
What age is the person who is seeking a group? *
Your answer
What gender is the person? *
Which location is best for you? *
What days and times work best for you (or your child/teen) to participate in a group? Check all that apply. *
morning (9:00 - 12:00)
early afternoon (12:00 - 3:00)
after school (3:00 - 6:00)
evening (6:00 pm - 9:00 pm)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Please provide us with some more information about the types of symptoms/issues you want addressed in a group (i.e. divorce/separation; grief/loss; social skills; anxiety/depression) *
Your answer
Is the potential group member currently in therapy?
Please provide your email so that we may contact you. *
Your answer
What is the best phone number to reach you? *
Your answer
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