Group Interest Form

First name

Last name

Email

Phone

What is your availability? Please be specific about days and times. (E.g Mon 8-10am Thur 9+ pm EST)

What is your current relationship status?

Do you have a group facilitator preference?

Which phase of healing best describes where you are currently?

Do you currently have support in your healing process?

Which areas feel most important for you right now? (select up to 2)

What type of group format do you prefer?

A structured group (focuses on learning tools and skills using a workbook

A process-orientated group ( time for each participant to share and receive support)

A combination of both

I'm open to either

How did you hear about our support groups?

If you selected “Other,” please specify:

Is there anything else you would like to share or ask?

Past Groups