Group Screening
Submission Form
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First Name
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Last Name
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Email
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Phone Number
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Please review the screening questions below and answer to the best of your ability. Your responses will be carefully reviewed by the group leader. If you have any questions or concerns, reach out via email to amakapsychotherapy@gmail.com
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Are you over the age of 18?
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What brings you to consider joining this group?
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What are your goals or expectations?
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Do you have any medical or psychological conditions that may affect your participation in group therapy? If yes, please describe.
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Are you currently receiving individual therapy or any other form of mental health support?
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Are there any specific issues or topics you hope to address in this group?
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Are you comfortable sharing personal experiences and insights with others in a group setting?
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Are you able to commit to attending group sessions regularly and actively participating in group discussions
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Is there anything else you think would be important for us to know about you before joining the group?
SELECT PAYMENT METHOD
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CREDIT CARD
CHECK OUT WITH
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Name On Card
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Card Number
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Month
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2018
Year
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CVC
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RESERVE MY SEAT
ORDER SUMMARY
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8 Week Support Group
$360
Invest in your mental health today! To pay in weekly installments, reach out to amakapsychotherapy@gmail.com In the case that you are not accepted to this group, your payment will be returned to you within 5-10 business days.
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Not sure which group is the right fit for you?
Schedule a call to discuss further.
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Book Consultation Call
Book your free 15-min consultation
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