Group Therapy Interest Survey
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Gender
Male
Female
Non-binary
Prefer not to say
Group Therapy Preferences:
Type of Group
Support Group
Psychoeducational Group
Process-Oriented Group
Skills Development Group
Topics of Interest (Check all that apply)
Anxiety
Depression
Stress Management
Relationship Issues
Grief and Loss
Self-Esteem
Trauma Recovery
Addiction Recovery
Anger Management
Life Transitions
What type of therapy group are you interested in?
*
ADHD Group
DBT Group
Preferred Time for Group Sessions
Morning
Afternoon
Evening
Weekdays
Weekends
Goals and Expectations:
What are your goals for participating in group therapy?
What do you hope to gain from the group experience?
Is there anything specific you would like the facilitator to know about your preferences or needs in a group setting?
Submit
Should be Empty: