EmpowerHER Women's Circle
Welcome! We are excited that you're interested in joining the EmpowerHER Women's Circle (a therapeutic support group), meeting in person in Hillsdale, NJ, on Monday evenings. To join the waitlist for the next six-week series, please complete the form below and either Michele or CJ will contact you with more information. 

To learn more, visit us on our WEBPAGE, FACEBOOK, or INSTAGRAM 
Sign in to Google to save your progress. Learn more
Name (first and last) *
Email *
Phone *
What is your age? *
How did you hear about this group? *
Have you ever been diagnosed with a mental health condition? If so, please provide a brief explanation (keep in mind this is not a HIPAA compliant platform).  *
Are you currently receiving individual therapy or psychiatric care? (please select all that apply) *
Required
What are you hoping to gain from participating in this group?  *
Do you feel you are in a stable place emotionally and mentally to participate in a group setting?  *
Have you ever experienced significant challenges in group settings (e.g. conflicts, discomfort sharing)? If so, please explain briefly.  *
This group is a safe, supportive space. Are you comfortable with respecting others' perspectives, maintaining confidentiality, and contributing positively to the group dynamic?  *
Do you plan to use insurance to offset the cost of the group? 
 *
If you answered "yes" or "not sure" to the question above, please provide the name of your insurance plan.  *
Do you need to discuss payment arrangements? *
Is there anything else you'd like us to know about you before joining this group? *
Thank you for taking the time to complete this form. Michele or CJ will contact you soon! 

Please note that space is limited to TEN (10) participants and registration is confirmed upon receipt of payment. 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bodhi Counseling & Wellness, LLC.

Does this form look suspicious? Report

Google Forms