Group Therapy Screening

Simply Redefining Wellness & Counseling GROUP THERAPY INTEREST & SCREENING FORM

Complete this short form to help us determine the best group for your needs. A member of our team will follow up with next steps.

Name

Preferred Name/Pronouns

Birthday

Month

Day

Year

Phone

Email

Which group are you interested in?

What made you interested in joining a group at this time?

What are you currently experiencing? ( check all that apply)

Multi choice

Anxiety

Depression

Stress/Overwhelm

Anger/Irritability

Grief/Loss

Trauma-related symptoms

Relationship concerns

Substance use concerns

Other

Group Therapy Screening