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NeuroWonder Support Group Screening Form
Group details and dates can be found here: https://www.kintherapyseattle.com/groups
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Full name and pronouns:
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Your answer
Email:
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Your answer
Phone #:
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Your answer
How did you find out about the group?
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Therapist
Friend/Family member
Social media
Inclusive Therapists website
Internet search
Other:
If you were referred by a therapist, please list their name below:
Your answer
Your identified neurotype (e.g. autistic, ADHD, AuDHD. Please note self-diagnosis is as valid as "official" diagnosis)
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Your answer
How long have you known about your neurodivergence?
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Your answer
What do you hope to get out of this group?
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Your answer
Are there any accommodations and/or accessibility needs that would help you best participate in the group? (e.g. captions during group sessions, communication preferences, video or audio preferences, etc.)
Your answer
Is there anything else you would like to share/comment on/ask about?
Your answer
In order for our group to be a safe and welcoming space, below are the guidelines you are asked to abide by as a group member. Please check each one to acknowledge you have read and agree to these guidelines.
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Be kind and respectful toward others in the group
Ableism and bias will be addressed: we will name when it happens and work toward a different narrative.
Use I statements when describing your feelings and sharing with others
Confidentiality - do not under any circumstances share what you hear in this group with others
Ensure you can engage in good self-care practices to take care of your needs both during and after group
Remember intersectionality when hearing/sharing experiences
Required
FEE POLICY
The fee for one group session of 90 minutes is $90; group total fee for 9 weeks is $810.
Group members pay for all 9 sessions regardless of attendance
. In order to register, a $40 non-refundable deposit is required to hold your spot. Payment is due at the end of each session and you are required to have a credit card on file in order to be billed. My practice is private pay only, no insurance is accepted and no superbills will be provided for group sessions.
Please indicate below that you have read and agree to the fee policy for this group.
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I understand and agree
Support groups are not therapy nor are they substitute for therapy. This is a closed 9 session support group held via Zoom.
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I understand and agree
Upon completion and review of your submitted form, you will receive an email invitation to set up your client portal, where you will be asked to fill out several forms (group guidelines form, group telehealth consent form, demographics form, release of information for emergency use form, and a credit card form).
Once you enter in your payment information, your card will be charged for a non-refundable $40 deposit to hold your spot and you will be officially registered for the group. You will receive an email with link to access the online meeting one week prior to group's start.
I understand and agree
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