Take Up Space, Amiga!

Name *

First Name

Last Name

Phone *

(###)

###

####

Can I send a text message to this number? *

Yes

No

Can I leave a voicemail at this phone number? *

Yes

No

Would you like to be added to the waitlist of the next cohort if this group is full? *

Yes

No

Would you like to receive updates regarding support groups and other Healing Corazones Psychotherapy Services? *

Yes

No

How did you hear about Healing Corazones Support Groups? *

Healing Corazones Psychotherapy Website

Friend

Web Search

Social Media

My therapist

Other

Are you currently in individual therapy? *

Yes

No

Are you experiencing any difficulty at this time that might make it hard for you to focus on issues relating to this group? *

Yes

No

Engaging in conversations regarding certain topics can be difficult/triggering. Do you have a support person or therapist to talk to if something during the discussion is upsetting to you? *

Yes

No

Are you available to be present for the duration of all group meetings (8 meetings total starting in February 21st-April10th, 2024)?

Yes

No

Not sure

Do you need any accommodations in order to participate in the group? *

Yes

No

Not sure

Are you open to completing a questionnaire at the end of the last meeting to provide feedback regarding your experience in the group? *

Yes

No

Not sure