Group Support Application
Mental Fitness C.R.E.W: Center for Resilience Empowerment & Wellness
Your Name
*
First Name
Last Name
You child's name (if they will be the participant)
First Name
Last Name
Your child's age
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Which group are you applying for?
*
Adults with Chronic Illness
DBT for PANS/PANDAS children
Support for Parents of PANS/PANDAS
Support for Siblings of PANS/PANDAS (if multiple siblings, complete one application per sibling)
Will you be attending via:
*
In-Person
Virtual
What days work for you to meet (check all that apply):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What times work for you to meet (check all that apply):
7-9am
9-11am
12-2pm
3-5pm
5-7pm
7-9pm
What are your primary reasons or concerns for seeking group support at The Mental Fitness C.R.E.W: Center for Resilience Empowerment & Wellness?
*
Group will meet twice a month for 90 minutes and will last 3 months. Once we find a group day/time that fits your schedule, you will receive a group contract to complete indicating your three month commitment. The total cost for 3 months will be $270. It will be collected up front and is non-refundable if you do not attend. We do not bill insurance for group costs. Are you willing to accept these terms?
*
Yes
No
Submit
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