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* 1. What is your full name?

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* 2. Which of the following describe your type of degree (can pick more than one): 

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* 3. What is your therapy license number and in which state are you licensed?

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* 4. What is your therapy license renewal date?

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* 5. How many years have you been in practice?

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* 6. Do you have your own malpractice insurance?

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* 7. Have you run therapy groups before?

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* 8. If you answered yes to question 7: How many years did you lead groups? What kinds of groups did you lead (e.g., couples, women, teens, etc)?

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* 9. Possible dates/times available for 8 week sessions (Note: Sessions run once a week for an hour. Also, some moms prefer weekends and evenings after 7 pm):

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* 10. Do you have reliable access to wifi?

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* 11. Do you have reliable access to a computer equipped for video chatting (e.g., audio and camera system).

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* 12. At what email address would you like to be contacted?

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* 13. How did you learn about Mother Squad, Inc.?

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