SynChronic: Support Group for Chronic Illness & Chronic Pain

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Every Sunday, 4-6 pm
12 Online Themed & Guided Sessions
with Acquilin John (As We Find It) & Rashi Vidyasagar (Director, The Alternative Story)

Email *

Name *

Phone Number *

Is this your whatsapp number? If not, please provide. *

Yes

Other:

What is (or was) your profession/stream of education?

What is your age? *

Below 20

20-45

Above 45

What's your gender?
*

Please confirm that you have a chronic illness or are currently suffering from chronic pain. *

Yes, I do/am

No, not currently

Please confirm that you have been affected by chronic illness or chronic pain for at least 6 months *

Yes I have

No I have not

Not sure

Are you currently in counseling/therapy or have you previously undertaken counseling/therapy? *

Yes but not for my chronic conditions

Yes for issues including my chronic conditions

Would you mind briefly discussing the nature of your chronic illness or the underlying cause of your pain, if any? If there is no discoverable cause, that is okay too. This information will be kept confidential.

Do you have any other conditions or disabilities that you would like to share with us?

What would you say are some of challenges as a chronically ill person? We will try to accommodate these themes as group discussions.
*

Are there any accommodations you require? (e.g. closed caption)

Are you tentatively available between 4 & 6 pm on the following days?
March 31
April 7, 14, 21, 28
May 5, 12, 19, 26
June 2, 9, 16
*

Yes, all days

Not available on most of these days

Other:

Send me a copy of my responses.

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