Inner Coach Counseling Group Therapy Interest Form
I am sending you this interest form because have expressed an interest in one or more of my groups. Our next group is entitled ‘Slay Your Inner Critic’ that will begin on October 12, 2019 through November 16, 2019. Please go to
for additional information.
Are you interested in the ‘Slay Your Inner Critic’ Group?
This process group is for women of color, ages 25 and older who want to get rid of negative self talk and self sabotaging behaviors to improve how they feel about themselves and how others experience them. Members will be screened and interviewed to determine the appropriate fit, as this group is not for everyone. The group is to explore new and healthier patterns of thinking to slay the inner critic. The members will engage in activities such deep breathing, relaxation techniques, visualization, tapping, self hypnosis, and other complementary modalities to help eliminate your Inner Critic and discover your Inner Coach within. As a result, this group will help empower you to elevate your self confidence, acknowledge and activate your self worth, and uncover and tap into your self love. The group sessions will meet every Saturday beginning on Sat. Oct. 12 thru Nov 16. at 2751 Buford highway ATL Ga. from 12 PM until 1:30 PM. All 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. If you are unable to commit to the six sessions, and then try scheduling for the next upcoming groups. No make up sessions are offered and if you pay in advance for the session, no refunds will be provided for any missed sessions. Please note that this is a closed group. Once the group begins, no new members will be added. Some members may uncover painful and difficult experiences, however, the group is designed to be a space for supportive healing. 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 six sessions, with one excused absence. 4. Not smoking, using alcohol or drugs during or just prior to the session. 6.Not interrupting others when they are speaking. 7. Being respectful of other members of the group including the facilitator. 8. Paying on time. 9. Respecting 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. Discourages group member interactions outside of group. 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
The cost of the group is $45 per person/session ($270). However, I have 2 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 2nd payment) at the beginning of the 4th group session ($18 savings). Option 3- Pay $45 per session.
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).
I understand that in order to secure my spot in the group, I must make a payment no later than October 5, 2019
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
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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