(April) Fools Group Therapy Interest Form

Hi! Thanks for your interest in the April Fool’s Somatic Therapy Group!

This 4-week therapy group will explore somatic healing through play, movement, relational connection, and parts work led by Emily Madeira, LMSW and Becca Chapman, MAT, SEP.

This short form helps us gather your basic information, learn a little about your interest in the group. After reviewing your responses, we’ll reach out to schedule a brief consultation call where we can answer questions and talk through next steps.

This is a closed group, therefore the same participants will stay together for the full 4 weeks. Space is limited.

All information shared here will be kept confidential.

Sign in to Google to save your progress. Learn more
First Name
Last Name
We'll be reaching out to you to schedule consultations/intros over the next couple weeks. 

How would you like to be contacted?
Clear selection
Phone Number
Email Address
Preferred Pronouns
In order to build a container where we can build safety, we would like folks to attend all 4 sessions. Are you able to attend all of the following dates and times?

~ April 16th 6-8pm

~ April 23rd 6-8pm

~ April 30th 6-8pm

~ May 7th 6-8pm

Clear selection
Is there anything else you'd like us to know or questions you have for us?
How did you hear about this group?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Tides Center For Wellness, LLC.

Does this form look suspicious? Report

Google Forms