These questions will take about 7 minutes to complete. Please answer all of the questions. 

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* 1. Name

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* 2. Address

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* 3. Your pronouns

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* 4. Age / Date of Birth

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* 5. Email address

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* 6. Phone

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* 7. Which group are you interested in joining?

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* 8. Briefly share information about yourself / your story / the particular circumstances that bring you to this group:

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* 9. Why are you interested in this group? What issues do you hope will be addressed?

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* 10. All of the groups that Irene runs operate through a socially conscious lens. They are intended to be anti-racist, queer-friendly, sex-positive and poly-friendly. Humans who share and support these views are welcome to participate. In what ways does this approach match your own views or lived experience?

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* 11. What concerns (if any) do you have about being in the group? (Check all that apply.)

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* 12. In terms of the time/day options when the group could meet:
The biggest challenge in getting a group going, is having a minimum of 4 people whose schedules match. Irene does make flexibility in her schedule for the groups that she runs.

Most groups meet 1.25 hours or 1.5 hours. Group length depends on the number of members and the type of group. For the sake of getting a general idea of prospective group members' availability, the options below are listed in two-hour blocks.

Which of the following days and times could you make work? Check all that apply. 

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* 13. Which group format would you prefer?

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* 14. If you are currently or recently in any type of counseling, would you be willing to sign a Release of Information Form? This would give Irene and your provider permission to consult before and/or during your time in group.

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* 15. How did you hear about this group? (Check all that apply.)

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* 16. Anything else you want to add? / Do you have any questions?

0 of 16 answered
 

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