Name *

First Name

Last Name

Phone *

(###)

###

####

Availability to Start this Session? *

See dates/times posted in banner at very top of website for when the next series starts.

Yes!

No, I'll have to wait until the next round. Please contact me when the next one is scheduled.

Days/Times You'd be Available for Future Groups: *

Answer this even if you answered yes above. Check all that apply.

4:30 on Mondays

10:15 on Tuesdays

6:30 on Tuesdays

9:15 on Thursdays

5:30 on Thursdays

How much do you know about the science of chronic pain, neuroplasticity, and the mindbody approach to healing? (Absolutely none is required.) *

None

A little bit

A fair amount

Quite a lot

I might offer these groups in the future. Do any of these interest you? *

Check all that apply.

Growing in Shame Resilience

Flourishing as a Highly Sensitive Person

Coping with Emotionally Immature Parents

Living with Better Boundaries

Learning to Trust Your Own Deepest Wisdom

How did you hear about me? *

Check as many as apply.

Web search for a psychotherapist

Web search for help with chronic pain or other health problems

Facebook ad

Google ad

Friend

Other

Please check each box below to acknowledge that you have read and understand each item. *

Submitting this form allows me to help you figure out if this group is right for you. It is not a commitment to participate.

This group meets via videoconferencing and requires you to use a computer or tablet.

Participation in this group will not heal your problem per se; it is up to you to employ the skills you learn in order to heal.

You will get the most out of this group if you watch a brief video (20-30 min) before each session.

You will need to pay up front for the entire series before the group begins.

You will need to be physically located in the states of NH, FL or AZ while the group is meeting (because of licensing laws).