Group Therapy Intake Form

Please correct the errors described below.

For residents of Indiana, Florida and South Carolina ONLY at this time.

    Please upload a file

    Below is a list of problems that people sometimes have in response to a very stressful experience. Please reach each problem carefully and then rate how much you have been bothered by that problem in the past month.

    Please rate each according to how bothered you have been during this time.

    0 = Not at all

    1 = A little bit/Once a week

    2 = Moderately/2-3 times a week

    3 = Quite a bit- 4-5 times a week

    4 = Extremely/ 6-7 times a week

    Eating Disorder & Trauma Group Therapy Questions Only

    Please answer the following questions based on the last 6 months.


    Group sessions meet once a week for 1.5 hours at a time.


    The fee for our group therapy is based on a sliding fee. We do not accept insurance.

    Cameras & Attendance:

    Attendance in this program is with your camera on, participating in a quiet space where you are sitting down. You may not be driving around or walking around in your home during groups. As you log into group, you will need to send your therapist an email with your exact location (address/city/state) due to licensure and emergency protocol for the therapy group. If you need to cancel a group, please notify your group facilitator by replying to the email you receive with your login.

    You will receive an email from us which will be encrypted. The first email you will need to set a passphrase that you will use for your future emails from us.

    You will hear from someone within the next 2-3 days excluding Saturday to Monday.

    Your information will be encrypted.