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The Healing Circle: Participant Interest Information Form
Please provide the following information to help us tailor 'Women Navigating Conflict, Distance, and Loss in Friendship' to your needs.
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Full Name
Your answer
Preferred Pronouns
She/Her
They/Them
He/Him
Other (Please specify)
Prefer not to say
Clear selection
Email Address
Your answer
Phone Number (for urgent communication only)
Your answer
Date of Birth
MM
/
DD
/
YYYY
How did you hear about 'The Healing Circle'?
Friend/Word of Mouth
Social Media (e.g., Facebook, Instagram)
Website/Online Search
Therapist/Counselor Referral
Flyer/Community Board
Other
What is the primary reason you are seeking support from this group specifically focused on friendship?
Your answer
Which topic most closely aligns with your current experience?
Navigating Conflict in a friendship
Experiencing distance/drift in a friendship
Coping with the loss/ending of a friendship
A combination of the above
Other (Please specify)
Clear selection
On a scale of 1 to 7, how much emotional impact has your friendship challenge had on your overall well-being in the last 6 months?
Minimal Impact
1
2
3
4
5
6
7
Extreme Impact
Clear selection
Have you participated in a support group or therapy focused on relationships before?
Yes, a support group
Yes, individual therapy
Yes, both
No
Clear selection
Are you currently receiving individual mental health support?
Yes
No
Clear selection
Please rate your familiarity with concepts like boundaries, active listening, and emotional regulation.
Not Familiar
Somewhat Familiar
Very Familiar
Boundaries
Active Listening
Emotional Regulation
Not Familiar
Somewhat Familiar
Very Familiar
Boundaries
Active Listening
Emotional Regulation
Clear selection
What do you hope to gain or learn from being a part of 'The Healing Circle'?
Your answer
Do you have any accessibility needs (e.g., visual, hearing, seating) I should be aware of?
Your answer
This group meets in the evenings on Wednesdays from 6pm-7:30pm EST, Can you attend
all or most of the 8 weekly sessions
?
Yes
No
Clear selection
How important is anonymity and confidentiality to you in this group?
1
2
3
4
5
Clear selection
Are you currently experiencing thoughts of self-harm or suicidal ideation?
Yes
No
Clear selection
The 8-week group costs $520 total, over the course of 8 weeks. ($65 per session). Would this investment work for you at this time?
Yes
No
I would like to discuss a sliding-scale option
Clear selection
Please share any additional information or concerns you would like the facilitators to know before the group starts.
Your answer
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