Application for Open Source

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Welcome! Please complete the following application if you are interested in joining one or multiple Open Source Support Group Series. Applications are accepted on an on-going basis. Once received, you will be contacted via email to schedule free Initial Phone Consultation.

This form is hosted by Living Story Therapy, PLLC and is HIPAA-compliant meaning that any personal health information disclosed will be kept confidential.

Email *

Application Date

YYYY

First Name *

Last Name *

Email Address *

I consent to receive emails from Living Story Therapy, PLLC at the address I have listed above. *

YES

Phone Number *

I consent to receive phone calls and voicemails from Living Story Therapy, PLLC at the phone number listed above. *

YES

Scheduling Disclaimer

There are two separate Open Source 6-week Series, Insight and Connect. For more information, please review our webpage, https://www.livingstorytherapy.com/opensource

Due to the nature of group therapy, it is expected that group members will attend all group sessions for the full duration of the group series they choose.

Please describe your current relationship status and/or structure below.

Current Structure *

Polycule Disclaimer

To avoid conflicts of interest and dual relationships within the group, you are expected to attend group sessions alone. You are also not permitted to attend a group that includes your current partner or any member of your current polycule.

I acknowlege and understand the disclaimer listed above. *

YES

NO - Please list your concerns below in the Other box

Other:

Required

Facilitated Support Group

Open Source: A Non-Monogamy Support Group is considered a facilitated support group. This means each group session will be facilitated by a licensed therapist and will focus on a specific theme related to the practice of consensual and ethical non-monogamy. It is important when engaging in group therapy to be willing to talk openly about your thoughts and feelings, to honestly report your behaviors, to offer helpful, clear, direct feedback to others, and to listen fully and carefully to other members’ reactions to you.

I am willing to speak openly about my lived experiences, share my honest thoughts and feelings, and offer helpful and direct feedback to other group members. *

YES

Please list 1 to 3 goals and/or hopes you have for attending this group below.

My Goals *

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