Intake Request - Navigating Ethical Non-Monogamy Therapy Group

Please fill out this form to schedule your 15-minute intake call with Yana Tallon-Hicks to determine your eligibility for the educational support group, Navigating Ethical Non-Monogamy.


Please note: GoogleDocs, GoogleForms, and/or email are not secure or confidential ways to communicate. Never send sensitive or confidential information via these formats unless you have carefully considered the risks in doing so.

Please only use this GoogleForm to request an intake if you have considered the confidentiality risks of doing so.

Your first & last name *
Further personal information like your last name will be collected in-person during our intake call.
Your answer
Your date of birth *
Your pronouns (optional):
Your answer
Your email: *
Please leave the email address/es that you'd like me to use to send you relevant intake materials and group homework assignments.
Your answer
Your phone number (for our intake call): *
Your answer
When is the best day & time for our 15-minute intake call? *
Your answer
Do you plan to attend group with a partner or partners?
Have you ever attended a support group before? *
What brings you to this group? Please briefly describe any goals or hopes you have for your time in this group setting. *
Your answer
Do you have any concerns or questions about the group? If so, please list them briefly. *
Your answer
What has been your current experience with ethical non-monogamy? *
Please briefly describe any benefits and struggles you find important to highlight.
Your answer
This group is based on the principle that ethical non-monogamy is inherently different than cheating or infidelity as all partners involved in ethical non-monogamy are aware of and consent to the boundaries and agreements of the relationships they are engaged in. By joining this group, you are committed to bolstering your personal and relational skills that support this inherent difference. *
Are you currently experiencing a medical or mental health crisis? *
Do you currently struggle with substance abuse? *
Do you require any accommodations in order for your office visit to be accessible to you and/or your partner/s? If so, please list.
The Couples Center of the Pioneer Valley is only accessible via staircase and the building is without an elevator. This building has two gender-neutral bathrooms. This group will be held again in a different, more physically accessible space in the near future.
Your answer
Group fees are $35 per person, per session, due at the start of each group. No insurances are accepted. Would you like to be considered for a sliding scale?
All group fees can be paid via cash, check, or via Venmo/PayPal. There are a limited amount of sliding-scale fees available for clients adversely affected by socioeconomic factors. Please indicate if you'd like to be considered for a sliding-scale appointment below. If you are able to pay fees in full, you will be creating more space for others to receive sliding scale rates.
Anything else that's important for me to know about your intake?
Your answer
Please check here to confirm that you are 18 years old or older. *
Sorry, this group is not open to minors.
I have read the policies regarding this group such as fees, attendance, etc. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms