Coming Out Support Group Registration

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The Spiritual Care Team at the Unstuck Therapy Group is so pleased you are registering for this kind of care for yourself. Please let us know how else we can serve your needs as we enter into this sacred space for story sharing, connection, and support.

Name *

Age *

Date of Birth *

YYYY

Gender Identity *

Preferred Pronouns *

Cell Phone Number *

Email Address *

Physical Address: Street, City, State, and Zip Code *

Is it ok to leave messages on phone and/or email address? *

Occupation *

Who lives with you in your household (name/ages)? *

Please name the five most important people/animals in your life at this time. *

Are you happy at your current job? If no, please explain. What would you rather be doing? *

Describe your education history. *

Do you identify as a member of a certain religious or faith community? If so, please name/describe the community. *

Please name an emergency contact along with their phone number and email address. Including this person's name and contact information indicates your consent for me to reach out to this person if there is an emergency. *

Please describe your current relationship with alcohol and any other substance. *

Describe any mental health care you have received. *

Have you ever received any type of coaching or spiritual direction in the past? If so, describe that experience. *

What are your expectations/hopes for the coming out support group? *

Please share any other information you think would be helpful for the start of our time together. *

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