Inner Coach Counseling Group Therapy Interest Form
Welcome and Thank You for interest in our group offerings. We are excited that you have taken a wonderful step toward your healing!
Although groups are usually face-to-face; however, due to the current state of our country, the following groups will be held virtually. There is no better time to finally work through your struggles as our nation undergoes 'social distancing' mandates, work from home recommendations, local curfews and imposed quarantines. If you are serious about being a member of one of the following groups please complete the information as soon as possible. The minimum membership to any group is 4 members and the maximum is 10 members. Once I have completed the initial assessment on appropriate members the groups will begin promptly.
First and Last Name
Please indicate which group you are interested in
Social Anxiety and Self Esteem Group (6-Week Closed Group)
Black Womens Empowerment Group (Ongoing- Open Group)
Coping with Immigrant Parents Support Group (On-going Open Group)
The Boyfriends' Group- For the boyfriends, fiancee's and husbands of woman who care (6-Week Closed Group)
Slay The Inner Critic and Self Esteem Group (6-Week Closed Group)
Workplace Microaggression and Racial Fatigue Group for Women of Color (On-going Open Group)
Overcoming Test Anxiety Group (6-Week Closed Group)
Members will be screened and interviewed to determine the appropriate fit, as certain groups are not for everyone. Closed groups run for 6 weeks. Open groups are on-going with new members being added along the way. Both types of groups are designed to explore new and healthy patterns of thinking, behaving and communicating for positive change. Members increase understanding through group sharing and dynamic. As members, you will witness the struggles of others, receive feedback and see how you may also demonstrate similar qualities. The aim of the groups is to help empower, you, improve your emotional intelligence, acknowledge and activate your self worth, become a better communicator, set clear boundaries and heal your relationships by healing yourself first. Along the way, you will be stretched to learn valuable tools needed for healthier work experiences, family interactions and romantic relationships. Members may be encouraged to engage in activities such deep breathing, relaxation techniques, visualization, journaling, worksheet exercises, role playing and other complementary modalities to shift old patterns. Some members may uncover painful and difficult experiences, however, the group is designed to be a space for supportive healing. and STRICT confidentiality. All closed group members are asked to commit to all six sessions. However, one excused absence is allowed but discouraged unless due to sickness or other emergency.Members will be removed if confidential and private information is breached, violated, shared or recorded in any format. If you are unable to commit to the six sessions, a closed group may not be for you at this time to maintain the integrity of the group. Make up sessions are not offered. No refunds will be provided for any missed sessions. Please note that some groups are open (meaning new members can be added) while others are closed group (once the group begins, no new members will be added). We ask that all members be mindful and respectful of the group rules which include: 1. Showing up on time for the session. 2. Staying the full 90 minutes. 3. Attend all sessions (for closed groups), with one excused absence. 4. Not smoke (marijuana), use alcohol or drugs during or just prior to the session. 6.Not interrupt others when they are speaking. 7. Be respectful of other members of the group including the facilitator. 8. Pay on time. 9. Respect the right to privacy and confidentiality of each member and his/her personal information . 10. Not sharing or disseminate (including video or audio) anything shared or discussed with anyone outside of the group. 11. Avoid group member interactions outside of group. You will be sent a consent form in addition to what has been stated here. Do you agree to the rules of the group?
Yes, I agree and will follow the rules of the group
No, I do not agree and have chosen not to attend
Cost of Sessions: The cost of the group is $45 per person/session ($270 for 6 week closed groups). However, I have payment options that offer a discount if selected : Option 1- Pay the entire six sessions ($240) prior to the first session to secure your spot ($30 savings). Option 2- Pay in two installments ($126-1st payment) due prior to first session to secure your spot and ($126 for 2nd payment) at the beginning of the 4th group session ($18 savings). Option 3- Pay $45 per session. Option 4-Pay $35 per session (for open and ongoing groups only).
Option 1 - Pay the full $240 for all 6 sessions ($30 savings)
Option 2- Pay in 2 installments ($126) each prior to the 1st and 4th sessions ($18 savings)
Option 3- Pay $45 per session using credit card on file ( must provide credit card).
Option 4- Pay $35 per session for ongoing, open groups
I understand that in order to secure my spot in the group, I must make a payment 7 days before the start of the group.
Yes, I understand. Here's the link to Option 1- Paypal.me/InnerCoachCounseling/240
Yes, I understand. Here's the link to Option 2- Paypal.me/InnerCoachCounseling/126
Yes, I understand. Here's the link to Option 3- Paypal.me/InnerCoachCounseling/45
Yes, I understand. Here's the link to Option 4 - Paypal.me/InnerCoachCounseling/35
Refund Policy: I understand that the only time a refund will be given would be five days prior to the beginning of the first session. No refunds will be provided after that time frame. Clients will not be refunded for any missed sessions paid in advance.
Yes, I understand the refund policy. Please send me the payment link to get started!
No, I do not agree with the refund policy and choose not to proceed with the group work.
Send me a copy of my responses.
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