Adult Therapeutic Art Application

The Epilepsy Foundation of Northern California's art program takes place every week on Mondays. Sessions will alternate every other week between (a) formal instruction from an art specialist and (b) creative sessions led by one of our support group leaders.

No previous art experience necessary!

When: Weekly on Tuesdays
Time: 11:00am-12:30pm
Place: Online-Zoom
Age: Participants must be 18 or older
Admission: FREE, Limited amount of space available (first come, first serve, waitlist available)

The arts provide participants with both verbal and non-verbal means to communicate, express emotions, and relieve tension. Participants will be provided with expressive art projects which honor their diverse emotional and physical needs. This is a strengths-based program, meant to assist participants in building their confidence, increasing their self-awareness, developing their coping skills while building meaningful relationships with their peers.

Sign in to Google to save your progress. Learn more
Email *
First Name
*
Last Name
*
Address *
City *
State
*
Zip Code *

Age

*
Cell Phone
Home Phone
Work Phone
Emergency Contact 1 *
Phone *
Relationship to Applicant *
Emergency Contact 2 *
Phone *
Relationship to Applicant
*
Applicant's Physician *
Physician's Phone *
Physician's Address *

Applicant's overall health

*

Does the applicant have any other medical conditions or physical disabilities?

*
Allergies?
*

Have you ever participated in a virtual or in-person support group? If so, how was that experience? 

*

What do you hope to get out of this group? 

*
If you have any experience in the arts, do you have a favorite art modality?

What kind of expressive arts are you interested in? (For example: writing, drama, music, gentle movement, visual arts)?

Due to limited space, please let us know if there's a month or season that you can commit attending until, so we can arrange to transfer your spot to another interested participant thereafter.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Epilepsy Foundation of Northern California.

Does this form look suspicious? Report