Feeling Together, Healing Together: Registration
Thank you for your interest in becoming a member of the group Feeling Together, Healing Together: A Process Group for Overcoming Emotional Trauma.
Please fill out the following form honestly and completely. At this time, we are only able to accept Georgia residents into the group. After submitting your answers, the group leader will contact you to schedule your free 30-minute intake session.
If you have any questions, please reach out to
kelly@sagecenteratlanta.com
or 678-235-8968.
Please note that all information submitted in this form is protected according to HIPAA law.
* Required
Name
*
Your answer
Preferred pronouns
*
Your answer
Date of birth
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MM
/
DD
/
YYYY
Phone number
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Your answer
Email address
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Your answer
Permission to contact
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Please check all forms of communication you are OK with:
OK to call and/or leave a voicemail
OK to text
OK to email
Required
Preferred method of communication
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Call
Text
Email
Required
Street Address Line 1
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Your answer
Street Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Emergency contact name
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Your answer
Emergency contact relationship to you
*
Your answer
Emergency contact phone number
*
Your answer
Emergency contact location (city & state)
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Your answer
I am applying for the Wednesday 6:30pm-7:30pm group starting on January 27, 2021
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Yes
No - put me on the waitlist for another group time
How did you hear about this group?
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Your answer
What do you hope to gain by participating in this group?
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Your answer
What concerns or questions do you have about being a member of this group?
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Your answer
Do you have access to a computer or smartphone with a forward-facing camera?
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Yes
No
What is the biggest challenge you are facing right now?
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Your answer
Have you ever had thoughts of attempting suicide?
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Yes, in the past 2 months
Yes, between 2 months and 1 year ago
Yes, over 1 year ago
No
Required
Are you currently receiving any other forms of counseling or mental health treatment?
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If yes, please describe: (e.g. individual therapy, participation in another therapy group, etc.)
Your answer
Is there anything else you would like us to know about you?
Your answer
Please list 3 times over the next 7 days in which you are available for a 30-minute intake session
*
Your answer
Electronic signature
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Your submission of this form does not guarantee group membership. Membership will be confirmed or denied by contact with the group leader, Kelly Pierce. By typing your legal name below, you are giving your electronic signature stating that the information submitted is true to the best of your knowledge.
Your answer
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