Application

Apply for the next cohort.

A brief intake to ensure this program is the right clinical fit. All responses are confidential.

Basic Information

Full name

Date of birth

Phone

Insurance provider (optional — this is a private-pay program)

Care Team

Do you currently have an individual therapist?

Clinical Screening

These questions help ensure group therapy is the safest, most effective level of care for you right now.

Have you experienced any suicidal ideation in the past 30 days?

Any history of suicide attempts?

Do you have any current mental health diagnoses?

Are you currently taking any psychiatric medication?

Your Goals

What are you hoping to get out of this group? (optional)

I understand this application does not guarantee acceptance into the program. A brief screening call is required to confirm clinical fit. If I am in crisis, I will contact 988 or go to the nearest emergency room.