Name *

First Name

Last Name

Have you been in a group before? *

Yes

No

Please indicate what type of group you're looking for *

Check all that apply

Curriculum based- psychoeducation, exercises, discussion

Process oriented- members share openly and work to connect, as well as provide and receive feedback

Either

I'm not sure

Please indicate current symptoms or problems you are experiencing *

Check all that apply

Anxiety- racing thoughts, constant worry, etc.

Depression- lack of interest in activities, changes in sleep or appetite, etc.

Loss of structure in schedule due to disability or unemployment (voluntary or involuntary)

Medical complications

Social isolation

Communication challenges in relationships

Anger

Irritability

Substance abuse/misuse

Other

Please indicate availability to attend group *

Check all that apply. Evening groups are not offered at this time.

Tuesdays 9am

Thursdays 1 or 2pm

Sundays 9am

Other