MindTree Group Therapy Interest Form
This form is to solicit interest in attending group therapy at MindTree. 
Sign in to Google to save your progress. Learn more
Are you a current or previous client of MindTree?  *
Legal First & Last Name
 *
Preferred Name (if different)
Email address *
Date of Birth *
MM
/
DD
/
YYYY
Phone number *
Pronouns *
(Dialectical Behavior Therapy)
Captionless Image
Clear selection
Substance Abuse Psychoeducation group with John Otts, LPC
Captionless Image
Clear selection
Political and Social Stress group
A non-partisan support group for those experiencing political stress and stress regarding current events.
Clear selection
This group is donation-based and not subject to insurance coverage. Register at https://petlossgriefsupport.eventbrite.com
Clear selection
Group therapy requires an assessment appointment prior to beginning group. 
If you are not an active therapy client of MindTree, are you okay with completing the assessment process? 
 *
Payment & Insurance Information *
Preferred days and times
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please let us know how you heard about our groups or who referred you. 

Your feedback helps us improve, and we appreciate your support!

Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of mindtreeholisticcounseling.com.

Does this form look suspicious? Report

Google Forms