Divergent Paths Counseling: Autistic & ADHDer Group Interest Form
Hi! I'm glad you're interested in learning more about the autistic & ADHDer process group.
Please fill out the form below, and I (Lila, she/her) will be in touch in the next few days so I can answer any questions you may have and so we can get to know each other better.

Please note that this form is stored on a HIPPA protected drive. I do not give you the option of sending a copy to yourself because this would break the HIPPA protection.
If you don't feel comfortable filling out this form for any reason, you can email me at lila@divergentpathscounseling.com.

I look forward to learning more about you!
-Lila
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Today's Date *
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First Name *
Last Name *
Phone Number *
Email Address *
Date of Birth *
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Why are you drawn to join this group? Please share a few sentences or more if you are able. *
What are some of your interests and personal strengths? *
Where do you place yourself on the support needs scale? *
Low support needs
High support needs
The current group meets every other week on Thursdays from 12:30-1:45pm. It is an "open" group (that is, no set end date, and you are welcome to wrap up at any time).

When there is enough interest, a new group will form. This new group will meet on a weekly basis and will also be an "open" group

Are you able to commit to attending all or almost all of this groups sessions? (Excluding vacations and illness).

If not, please explain a bit about why.
 *
Please check all times that you're able/prefer to meet. (Groups are 50min to 1:15 long depending on the size). *
9am
9:30am
10am
10:30am
11am
12:30pm
1pm
1:30pm
2pm
Monday
Tuesday
Wednesday
Thursday
Is there anything else you would like to share with me?
How did you find out about this group? *
Required
If you answered "other," "other directory," or "referral from a professional," could you share where/who?
Do you have any questions for me in this moment?
Thank you for completing this form.

I will reach out to you via email in the next few days and we can schedule a time to meet over telehealth or in person. This will be a time for you to ask any questions you may have and for me to get to know you better and make sure the group will be a space where you're able to get support and grow.

I look forward to meeting you!

-Lila Low-Beinart, MA LPCC
Neurodiversity-Affirming Therapist
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