Support Group Request Form
Our mission at New London Counseling Center is to break barriers to mental health care for every individual, family, and child in our community through the provision of high-quality mental health counseling services and connection support groups.

If you feel a need exists in our community that can be met by the creation of a connection group, please fill out this form so that our administrator can assess the request and respond accordingly. Because we strive to provide the highest quality experience for those we serve, we recommend securing the contact information of at least five other participants who are committed to attending and participating in the requested connection group.

Fees associated with support group attendance will be determined and discussed with the administrator at time of contact.
Email address *
Name *
First and Last
Your answer
Phone Number *
Your answer
Please list any businesses or organizations you are associated with:
Your answer
Please list any businesses or organizations your proposed group would be associated with, if applicable:
Your answer
What need is your group hoping to meet? *
i.e. addiction support, caring for loved ones with mental health needs, social skills for a specific age range, etc.
Your answer
What age range is your group hoping to serve? *
Your answer
Is your group specific to a certain population? *
i.e. gender identity, sexual orientation, cultural herritage, etc.
Your answer
Does your group have a location where you would like the sessions to be held? *
Your answer
Does your group require special arrangements? *
i.e. child care, special equipment, etc.
Your answer
How frequently would you like your group to meet? *
What day of the week would you like your group to take place? *
Required
What time of day would you like your group to take place? *
Required
Please list the name and email address of another interested party:
Your answer
Please list the name and email address of another interested party:
Your answer
Please list the name and email address of another interested party:
Your answer
Please list the name and email address of another interested party:
Your answer
Please list the name and email address of another interested party:
Your answer
Please share any other details you feel may be relevant:
Your answer
Would you like to be added to our mailing list for updates on future offerings and events from New London Counseling Center? *
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