Finding Calm in a COVID World: 6-Week Mindfulness Group
Thank you for your interest in being a member of the group "Finding Calm in a COVID World". Please fill out the following questionnaire honestly and completely. After submitting your answers, one of the co-leaders will contact you to discuss your membership in the group.

If you have any questions, please feel free to contact us at 678-235-8968 or

UPDATE: Registration for open groups is currently paused, but we will be releasing a new group time soon. Please continue with this form if you would like to be placed on a waitlist for future groups.
Name *
Preferred pronouns *
Date of birth *
Phone number *
Email address *
Permission to contact *
Please check all forms of communication you are OK with:
Preferred method of communication *
Street Address Line 1 *
Street Address Line 2
City *
State *
Zip Code *
Emergency contact name *
Emergency contact relationship to you *
Emergency contact phone number *
Emergency contact location (city & state) *
How did you hear about this group? *
What do you hope to gain by participating in this group? *
What concerns or questions do you have about being a member of this group? *
Do you have access to a computer or smartphone with a forward-facing camera? *
What is the biggest challenge you are facing right now? *
Have you ever thought of, planned, or attempted suicide? *
Are you currently receiving any other forms of counseling or mental health treatment? *
Is there anything else you would like us to know about you?
Electronic signature (Type full name) *
Your submission of this form does not guarantee group membership. Membership will be confirmed or denied by contact with one of the group co-leaders: Amber Amick, APC or Kelly Pierce, Counseling Intern. By typing your legal name below, you are giving your electronic signature stating that the information submitted is true to the best of your knowledge.
Never submit passwords through Google Forms.
This form was created inside of Kelly Pierce Counseling. Report Abuse