Once you have discussed any upcoming group participation with therapists Sylvie or Carla, please complete the form in full to register for the group. Your willingness to answer the questions below will help us best assess your group readiness.

Your participation in the group will be confirmed upon receipt of your payment/down payment and submission of the Group Readiness Form and the Informed Consent Form found under the "ABOUT" tab. If filled out here, this form will be electronically submitted.

* Indicates required field

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact Name and Phone Number

How did you hear about the group?

Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)

Yes

If yes, when? Please briefly list the reasons and outcomes.

Do you have a therapist you could work with if something came up in this workshop requiring individual attention?

Yes

Are you currently taking any medication for mental health issues?

Yes

If yes, please explain:

Are you in recovery from substances or behavioural addictions? If yes, how long have you been in recovery? Please provide a brief description of the treatment and supports you have and are currently receiving.

Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment you are/have 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 caused your interest in the group at this time?

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

What previous experience have you had, if any, with group therapy or a support group? Which groups did you attend?

If you have attended a support group, what was helpful? If you had any issues, what were they?

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

How would you respond as a group member if someone in the group dominated the discussion?

How would your respond as a group member if someone never participated in the group discussion?

What else would you like me to know about you?

Thank you so much for providing this information! I will review the information you provided and follow up with you to confirm your registration.

For questions or more information you may contact me at:
sylviesmith@phoenixrisingpsychotherapy.com