Breakup / Divorce / Separation Support Group Interest Survey

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I am forming an online "Breakup, Divorce, or Separation" Group for individuals seeking support around separation from a romantic partner or platonic relationship. Participants must be physically located in the state of Maryland while group takes place. The group will meet weekly via a platform like Zoom, and people of all gender identities and backgrounds will be welcome. The group will cost $100 per session and meet for 1 hour and 15 minutes each week. The group will have a minimum of three people and maximum of eight people. Please fill out the interest survey below if this group may interest you. I will follow up with you after you have completed the survey regarding possible next steps. Please know I cannot guarantee information shared through this document is electronically secure, so if there is something you are not comfortable putting in writing, no problem and we can talk about it. Thank you for your interest. You can learn more about me on my website at www.gottliebtherapy.com - Sincerely, Jessica Gottlieb, LCPC LLC - jessica@gottliebtherapy.com - 301-244-8257

Email *

First Name

Last Name

Phone

Below are the days and times the group may be offered. It will be offered at the same day and time each week. Please select all the days and times you could possibly attend.

Mondays at 9:30am

Mondays at 12:00pm

Mondays at 7:00pm

Thursdays at 11am

Thursdays at 12:00pm

Fridays at 8:30am

None of these work for me, but please contact me in the future should additional days and times become available.

Please read entirely: The group I am forming is what is called a "process group." It is a place for people to share in community, get support, and also receive feedback on how they are experienced by others in the group organically. The hope is that such feedback improves your life. Please read the description linked here which describes the type of group I will be offering.

If this type of group interests you, please tell me in the space below why you are interested in this group and what you hope to get out of it.

Please share below how you handle conflict with and feedback from others.

What positive attributes of yours do you think you will bring to the group?

By checking the box below, I acknowledge that I have read the entirety of this survey and its listed hyperlink material. I also attest that I will be in the state of Maryland when group takes place.

I acknowledge

Send me a copy of my responses.

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