Secure Contact Form

Thank you for contacting Quarternote Counseling. If you are experiencing a psychiatric emergency and/or are at risk of harming yourself and/or others, please do not use this form. Instead, please call 911, visit your nearest emergency room, or contact the Suicide & Crisis Lifeline by calling or texting 988.

Please complete and submit this form. Your submission will be encrypted and secure. Fields with a red asterisk (*) are required.

Thank you for contacting Quarternote Counseling and for your interest in participating in our upcoming "Creating Change" group. This group is tailored to those who have experienced trauma or addiction.

The focus will be on understanding your past and connecting to the present. Using Lisa Najavits’ work (“Creating Change”), you will gently explore how your past impacts your current experience and gain a new perspective on your personal narrative. Through Stephen Porges’ Safe and Sound Protocol, you will enhance levels of social engagement, resilience, and calm through music and nervous system regulation. The group may also include experiential exercises to reinforce these ideas. Join us - embrace the power of change and healing in a nurturing group focused on growth and recovery.

The group will be held Wednesdays, 6 – 7:30pm, in-person at Quarternote's office in Manassas
Duration of the group is 8 weeks (October 16 – December 11, 2024) PLEASE NOTE: The group will not be held the week of Thanksgiving, so there will be no group on Wednesday November 27th.
Cost: $330 total, to be paid in full upfront or in either two or three installments
Additional requirements:
- Smartphone that can connect to provided headphones
Register by October 9, 2024. Group will be filled on a first come, first served basis
Maximum number of participants: 12 people (ages 18+)

**There may be an option to add an additional 8 weeks depending on group interest**

Please read the following important information:

Submission of this form is to express your interest in group participation only. A 10-15 minute phone screening will be required to determine if this group is a good fit for you. The phone screening will take place after this form has been submitted and will be with the Group Lead Therapist, Wendy Freeman Rood, LPC, NCC.

In order to make the screening call as efficient as possible, some of the screening questions are provided below. If you are comfortable providing answers to all or some of the questions, please do so. This will enable Ms. Rood to keep the duration of the screening phone call to a minimum.

If the screening determines that this group is a not a good fit for you, or if the group has already been filled, you may ask to be placed on a wait list for a future group.

By checking this box I acknowledge that I have read and understand the information above.

First name

Last name

Phone number

May we leave a voicemail on this number?

Yes No

Email address

**Please note: It is Quarternote's policy to send emails via Hushmail, and in an encrypted state, in order to protect your information. Upon receipt of our email, you will be required to establish and use a passphrase in order to open the email. Please bear in mind that unencrypted electronic communication is permitted at your request, but is at risk for interception and could result in misuse of your personal information by unintended third parties. **

Email Preference

Yes, please use encryption when sending emails in order to protect my information and privacy No, please do NOT use encryption when sending emails. I understand and accept the risk involved and that my personal information may be intercepted by unintended third parties

Please indicate the best time to reach you for a 10-15 minute phone screening Please check all that apply

Mornings (8am-12pm)

Afternoons (12pm-5pm)

Evenings (5pm-7pm)

May we leave you a voicemail on the number provided above?

Yes No

SCREENING QUESTIONS (optional)

Answering these questions is not required, however, the information will be useful in the determination of whether or not this group is a good fit for you. The information provided below will reviewed by Ms. Wendy Rood before she contacts you for the phone screening process, and will decrease the amount of time needed for that phone call. If you choose to provide answers to the questions below please provide as much information as possible to the extent you're comfortable. You may answer all or as many questions as you wish.

1) What is your past experience with groups?

2) Why you to want to attend this group?/What do you hope to get out of it?

3) How do you feel about looking at yourself and your past?

4) How do you express your emotions?

5) How do you feel about talking about trauma/addiction? (level of disclosure is your own choice)

6) How comfortable are you with hearing others’ stories?

7) What triggers you? What might you need?

8) What strengths and abilities do you bring?

9) How committed are you to consistently attending?

Your information will be encrypted.

Secure Contact Form

Quarternote Counseling, LLC