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Fall 2022 Infertility Support Group
Please complete this form in its entirety. Your answers to these questions help group facilitators ensure that this group is a good fit for your needs. A group facilitator will contact you to discuss next steps following the completion of this form.
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Email
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Your email
Participation in this group is not covered by any insurance plans and a super bill cannot be provided for out of network reimbursement. The cost of participation should be considered an out of pocket expense. Please choose one answer below:
I understand.
I want to be connected to other resources that will allow me to use insurance.
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Group Details
Group Dates: Mondays. September 26, October 3, 17, 24, 31, November 7
Group Time: 5:00pm - 6:15pm
Group Cost: $195
Group Location: Join virtually from anywhere in Texas
First and Last Name
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Zip code
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Date of Birth (mm/dd/yyyy)
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Your answer
What is the best phone number for us to call regarding your request?
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Your answer
Do you consent to receiving voicemails regarding your request?
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Please describe your gender
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Are there any other identities that you hold which you'd like us to know about? (Sexuality, ethnicity or race, physical ability, etc.)
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Please describe your hopes or goals as they relate to participation in this group
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Please describe any past experiences with individual or group counseling and support groups
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Your answer
Briefly describe your mental health history and any diagnoses you may have received
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Your answer
Briefly describe your fertility journey up to this point
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Your answer
After you submit this form, a group facilitator will contact you to set up a free 15 minute phone call. The purpose of this call is to ensure this group is the best fit for your needs. What days and times (M-Th, 9am-5pm) are best for a facilitator to contact you?
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