A Therapy & Support Group

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

Thank you for your interest in joining our group. Good for you for taking this step towards your psychological well-being. Let me know how to get in touch with you and I'll provide information for next steps. The first day of group will be Monday, June 6th.

Name *

Email *

Phone Number *

Are you located in NYC? *

Yes

Sometimes

Is Columbus Circle accessible to you? *

Yes

Does Mondays, 7-9:30pm work for you? *

Yes!

It works but earlier would be better

Let me know if you do a different day

Are you comfortable meeting in person? *

Yes, I'm fully vaccinated

Yes, but socially distanced w/ masks

I'm a little uncomfortable

No, I'm only interested in virtual

If the answer to any of these questions is no, are you interested in Individual Counseling?

Yes

Maybe

Other:

Clear selection

BEFORE YOU SUBMIT: Schedule a quick intake appt by clicking the link below:

https://calendly.com/imaritheinnerstage/45-min-ind-session

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms