Registration Form

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Registration Form

Chronic Illness Support Group

A free virtual support group for individuals with chronic illnesses, invisible disabilities, and their families and friends seeking support in Texas.

When: Last Tuesday of Every Month from 5:30 PM - 7:00 PM CST

Where: Virtual Via Zoom

Who: Facilitated by Nathan Galvan, Licensed Professional Counselor - Associate, NCC Supervised by Jennifer Buffalo LPC-S, LMFT

If you've registered but haven't received additional information about the group, please check your spam folder or contact Nathan@luminarycounseling.com.

Are you comfortable completing registration through our note-keeping platform, Simple Practice, which includes signing the following forms?:

Consent for Telehealth,

Notice of Privacy Practices,

Chronic Illness Support Group Informed Consent,

and a Demographics Form

(Please note that registering through SimplePractice is simply for group participation and does not establish a client relationship.)

Yes

Other:

Full Name *

What are your pronouns? *

Email *

Phone Number *

Preferred Contact Method *

Phone

Mail

Required

Do you reside in Texas? *

Yes

Do you have a Chronic Illness or Disability? *

Yes

No, but someone close to me does

Please briefly describe your condition and how it impacts you *

Have you seen a mental health professional before?
*

Yes

Any current or previous thoughts of hurting your and/or someone else?
*

Yes

How did you hear about us?

Is there anything else you would like us to know?

Submit

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