Anxiety Group Screening Form

We’re glad you’re interested in joining our Anxiety Management Group. Before we get started, we’d like to learn a bit more about you to make sure this group is the right fit for your needs.

Your honesty helps us create a safe and supportive space for everyone. There are no right or wrong answers—just be yourself!

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Email *
This Group is for You If:
  • You want to better understand your anxiety and what triggers it.
  • You’re looking for practical tools to manage anxious thoughts and emotions.
  • You want to connect with others who “get it” and feel less alone.
  • You’re willing to participate in a supportive and non-judgmental group setting.
  • You’re ready to explore your thoughts and feelings with curiosity.
  • You’re committed to attending weekly sessions and practicing skills outside of group.
  • You feel comfortable participating in a virtual group setting.
  • You’re not in an immediate mental health crisis and feel stable enough for group work.
After reading the above, do you feel this group is a good fit for you? *
Name *
Is the person needing services over the age of 18? Please note Activate Counseling Services only treats adults.  *
Phone Number *
Group will be on Tuesdays from 6-7p and there will be 10 sessions. Are you able to commit to this?  *
This group will be virtual, do you have necessary equipment for telehealth/virtual sessions?  *
What state do you currently live in? *
How did you learn about us? *
If referred, who referred you
Will you be paying with insurance or out of pocket? *
If you are planning on using insurance, what current insurance do you have? *
A copy of your responses will be emailed to the address you provided.
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