West Coast Chronic Illness Therapist Consult Group

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This is a new group and I am currently gaining interest as well as common days and times for a consistent meeting. Please complete the answers to this form to be contacted about being a part of a consultation group when it begins. This Consult Group is for Therapists with Chronic Illness/Pain/Health Condition. This Consult Group currently is for folks on the West Coast to make scheduling a consistent meeting easier.

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Correo *

Name *

Email Address *

Type of License, Licensure State and Number *

State you reside in, if differnt than above.

Are you a therapist who identifies as having a chronic illness/health condition/chronic pain? (no formal diagnosis is needed)

Yes

Otro:

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What do you hope to gain from being a part of this consultation group? Select all that apply.

Case Consultation

Private Practice/Work tips as a therapist with chronic illness

Connection/Community with other Therapists with Chronic Conditions

Networking

Otro:

What days would you consistently be available for a 1-1.5hr long monthly consultation meeting?

Monday

Tuesday

Wednesday

Thursday

Friday

What times of day typically work best for your schedule? Check all that apply.

Mornings (8am-11am

Lunch time (11am-2pm

Later afternoon (2-5pm)

Evening (5-7pm

What is your commitement level?

I plan to be there monthly

I plan to be there as often as I can (more times than not)

I plan to come every once in a while

I like to know this is here in case I need consultation or support, but probably will not be a regular

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