Psycho-Education Group Pre-Registration Form 
This form is to pre-register for the upcoming Sanar Institute psychoeducation group series, "Breathing Through Boundaries" beginning April 28th. A gentle reminder this is an open style group; attendance is not mandatory per session. There will be a follow-up email with group dates and a recurring Zoom link to access group sessions. If you have flagged safety concerns, Sanar staff will follow up with you before joining the group space. 
Sign in to Google to save your progress. Learn more
Email *
First Name *
Safe Contact Phone Number *
Safe Email Address *
Age *
What are your gender pronouns? *
Psycho-education Group Timing 
Psycho-education group sessions are scheduled to be biweekly on Tuesdays from 1 PM - 2 PM. 
Does this work for you? 
(Reminder: Attendance is not mandatory per session)
Do you have a private space and/or headphones to participate in group services confidentially?  *
Do you have safety concerns that might impact your participation or the safety of others during group sessions?  *
If you selected "yes" to the previous question, please fill in your safety concerns below. Based on safety concerns, a clinician will privately follow up to safety plan further if needed.
In the past, have you received individual or group therapeutic counseling?
Clear selection
WELLNESS CENTER GROUP POLICIES
As a part of services, the effective and respectful use of the wellness center services is important so that all clients are familiar with the rules and regulations that strive to create a safe, respectful, inclusive, and empowering setting. Failure to abide by these rules can result in termination of services.

Confidentiality and Privacy Policy
● The identity of staff, fellow program participants, and other individuals may not be disclosed.
● During group sessions, other clients and staff may share sensitive or personal information. Please note that group sessions of any kind are confidential, and any outside disclosure of information learned about staff, clients, or volunteers may result in suspension or termination.
● The Sanar team members are mandated reporters and are required by the court of law to report the following instances: suspected abuse or neglect of a child or vulnerable adult or if the client poses an immediate threat to oneself or another.
● Please ensure you are in a private location where other individuals are not able to overhear your conversation.

Confidentiality and Privacy Policy Acknowledgement
(Checkbox) I acknowledge that I have read and understand the confidentiality and privacy policy for
Sanar's group services.
 *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Sanar Institute.

Does this form look suspicious? Report

Google Forms