Chronic Pain & Chronic Illness Support Group Interest Form

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Name: *

Email address: *

Phone number: *

Why are you interested in joining the chronic pain and chronic illness support group? *

Do you have a private space to use for group? *

Yes

Do you agree to maintain the confidentiality of group members and all information shared in group? *

Yes

Are you currently receiving regular mental health care?

Yes

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Do you have any thoughts of harming yourself or other concerns about your safety?

Yes

Clear selection

Are you interested in a sliding scale spot?

Yes

No, I can pay the full rate of $40/ session

Clear selection

Submit

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