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Group Registration
Welcome to the Vida Clinic and Seek Institute registration form for group therapy and support groups! In order to get you started, please complete the following information and someone will contact you to guide you in next steps.
Vida Clinic and Seek Institute are antiracist organizations that aim to play an active part in the process of healing and systemic change.
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Email
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Your email
Name of Person Attending Group (First & Last Name):
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Your answer
Date of Birth of Person Attending Group:
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MM
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YYYY
Email Address of Person Attending Group:
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Beginning the Week of October 18th, we invite you to participate in our adult group therapy sessions, led by our Senior Clinical Staff. Please select the group(s) you are interested in:
Discovering Wellness: Learning How to Recognize & Conquer the Effects of Stress & Create Peace in Our Lives (Thursdays Noon - 1:00 PM)
We Rise Together: Learning How to Harness Assertiveness Skills and Build Empowering Relationships (Tuesdays 5:30 - 6:30 PM)
We Build Resilience: Learning How to Recognize & Reverse the Effects of Burnout & Reconnect to Ourselves (Wednesdays Noon - 1:00 PM)
Journey Through Young Adulthood: Navigating Life’s Transitions for Individuals Ages 18-23 Years Old (Thursdays 3:00 - 4:00 PM)
We are also offering the following support groups for free of charge. Please select the group(s) you are you interested in:
Teacher Support Group (Tuesdays 5:30 - 6:30 PM)
Real Talk for Parents (6:30 - 8:00 PM)
We are also taking requests for new groups! Is there a group that you would like to see Vida Clinic offer? Please let us know what would best meet your or your family's needs:
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Status of Person Attending:
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I have not participated in Vida Clinic services before
I am an established Vida Clinic client
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Street Address of Person Attending Group:
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Your answer
City and State of Person Attending Group:
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Your answer
Zip Code of Person Attending Group:
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Your answer
Phone Number of Person Attending Group:
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Your answer
Language of Person Attending Group:
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English
Spanish
Other:
Language of Family:
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English
Spanish
Other:
We do not discriminate on the basis of sexual orientation, gender identity or expression. To provide a more respectful and inclusive experience, please provide any additional information you feel comfortable sharing about yourself and your identity.
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Gender of Person Attending Group:
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Female
Male
Prefer not to say
Transgender
Gender Fluid
Non-Binary
Unsure
Prefer to Self Describe Gender:
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Preferred Pronouns of Person Attending Group:
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She/Her/Hers
He/Him/His
They/Their/Theirs
Ze/Hir/Hirs
Prefer Not to Disclose
How would you describe yourself?
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Hispanic/Latinx
White Non-Latino/Caucasian X
Asian American
Indian/Alaska Native
Black/African American
MENA (Middle Eastern/North Africa)
Pacific Islander
Prefer Not to Say
Required
Prefer to Self Describe Ethnicity:
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How did you hear about us?
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I went to the Vida Clinic or Seek Institute website
I was recommended by a friend/colleague
I was referred to you by an area hospital or treatment program
I heard about you through my school district
I found you through a search engine (Google, Yahoo)
I found you on social media (Instagram, Twitter, Facebook)
I heard about you through an agency or organization (NAMI, HOME Center, Mano Amiga)
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A copy of your responses will be emailed to the address you provided.
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