Mind-Body Skills Group Intake Form
Enhance Resilience and Connect With Others

Mind-body skills groups are educational, supportive groups that offer participants an opportunity to learn strategies of self-care and experience evidence-based techniques to enhance well-being and resilience. These groups are open to one and all. No prior experience is required. To join, fill out this form to be notified of upcoming group opportunities. Each group consists of 8-10 participants.

We will contact you with the next steps to move forward.

Email *
Today's Date *
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Name (First and Last) *
What is your date of birth? *
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Mailing Address *
City, State, Zip *
Gender *
Relationship Status *
Spouse/Partner Name *
Do you have children? *
Are you under Medical Treatment? *
If yes, please list your diagnosis *
Do you see any other other practitioners in the integrative area? *
If yes, which area(s)? *
Required
Are you currently taking any medications? 
Name of Medication, 
How much do you take? 
How did you come to take this?
Please list below:
 *
*
Yes
No
Do you smoke?
Do you drink coffee?
Do you drink alcohol?
Do you drink soda?
Do you use other drugs?
Do you eat regular meals?
Do you sleep regularly?
Do you exercise
Are you overly stressed in your current work situation?
Are you overly stressed in your current home/family situation
Do you feel supported in your current work environment?
Do you feel supported in your current home/family situation?
Do you have a support system/network?
 *
Yes
No
Family
Friends
Spouse/Partner
Community Groups
Physician/Nurse
Church/Religious Groups
Other Healthcare Professionals
What feeds/sustains your life? *
What drains your life?
 *
What gives you a sense of hope?
 *
What is your greatest concern at this time?
 *
What do you see as your greatest hurdle at this time?
 *
Email address *
Cell Phone *
How do you prefer communications *
What is your availability?  *
Morning (8 am - 10 am)
Mid Morning (10am - 12 noon)
Afternoon (12 noon - 2 pm)
Mid Afternoon (2pm - 4pm)
Early Evening (4pm - 6pm)
Evening (6pm - 8pm)
Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Can you commit to a 8-week, 2 hour group session, once a week? *
Are you able to do a pre interview? *
Tell me about yourself and what interests you in joining a mind-body skills group.
 *
What specifically do you hope to work on in the group?
 *
Please let us know if you have any questions.

Are you interested in bringing mind-body skills groups to your organization? (Optional) Please list a contact person at your organization. 
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