Registration Form

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Registration Form

Participant Information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

How did you hear about this workshop? *

Would you like to be included on our e-mail list about future events? *

Yes No

Have you ever seen a mental health professional (i.e. licensed mental health therapist, psychologist, psychiatrist)? *

Yes No

If yes, when? Please briefly list the reasons. *

Do you have a therapist you could work with if something cam up in the group requiring individual attention? *

Yes No

Are you currently taking an medication for mental health issues? *

Yes No

Are you in recovery from substance use/abuse (including alcohol)? If so, how long have you been substance free? Please provide brief information on the support/treatment you received. *

Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues. *

What sparked your interest in this workshop? *

What would you like to accomplish as a result of attending the workshop? *

What previous experience have you had, if any, with group therapy or a support group? *

What type of group? How long ago? *

Was the group(s) helpful? *

Yes No Neutral

What difficulties, if any, did you have? *

What concerns, if any, do you have about participating in a group experience? *

What else would you like me to know about you? *

What is the best way to follow up with you? *

Phone Email

Thank you so much for taking the time to provide this information! I will review the information you provided and follow up with you for a pre-group chat and to discuss workshop placement.

For questions or more information, please feel free to contact me at (941) 932-1134 or [email protected].

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Creative counseling solutions of Sarasota, inc.

Home
About
CLINICAL SERVICES
WORKSHOPS
- The Daring Way™
- The Gifts of Imperfection
Connect
- Map