Rejuvenation Therapy Circle Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome! Thank you for your interest in joining the Rejuvenation Therapy Circle! This weekly in-person group will engage in wellness-focused activities (materials will be provided!), discuss solutions to current barriers, enjoy inspiring meaningful conversations, and experience connection with others inspired to feel rejuvenated in the new year!

Because space is limited to only 10 individuals, Dr. Miranda-Alfonzo, the group facilitator & licensed psychotherapist, does want to ensure that you this group is a good fit for you. By answering the questions below, she can help make this determination. Your answers will remain confidential and only be read by Dr. Miranda-Alfonzo, CPC, LCADC, NCC, ACS.

In the case of a higher demand, an additional group time might be added and/or a waitlist will be created.

Weekly Groups will be held on Tuesdays from 4:00 p.m.-5:15 p.m. at 2000 S. Eastern Avenue, Las Vegas, Nevada, 89104. The first group begins on Tuesday, January 24th, 2023. A private Facebook group will also be set up to encourage ongoing conversations between group meetings (this is optional for members).

The fee is $25 per group or $90/month via cash, Zelle, Cash App, or Venmo. A superbill can be provided for you to submit to your insurance, under group a psychotherapy CPT Code.

For any other questions, please email Roberta at roberta@ramabloom.com

Thank you, and cheers to a wonderful 2023!

Dr. RMA

Email *

Please provide your preferred name and pronoun (i.e. she/he/they)

Best email address to contact you. By including this, you are providing me permission to email you.

Are you over the age of 18?

Yes

Clear selection

What is inspiring you to join this group?

What might be potential barriers to attending our in-person group on a weekly basis?

What are a few activities you do for fun?

Are you willing to try new activities that can promote positive changes in your life?

Yes

Maybe

Clear selection

Members agree that participating in the Rejuvenation Therapy Circle may address personal, sensitive areas, and may cause emotional discomfort, as this is part of the healing process. Members also agree to practice confidentiality, and not share any personal information of other group members outside the circle.

I agree.

I disagree.

Clear selection

Thank you for completing the form!

I will respond to you as soon as I can. Again, please recall that the group max is 10, so if your enrollment is not approved at this time, it is most likely due to space limitations. In the meantime, please refer to my website ramabloom.com for additional updates, my bio, and other provided services (the website is currently being updated, thank you for your patience). Thank you and stay strong! :)

Dr. RMA

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of ramabloom. Report Abuse

Forms