Group Interest Form — ELLEN RONKA, LCMHC

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ELLEN RONKA, LCMHC

Chronic Pain, Fatigue & Other

ELLEN RONKA, LCMHC

Chronic Pain, Fatigue & Other

Folder: Services

Folder: Specialties

Chronic Pain, Fatigue & Other

Minding-The-Body Healing Group

an evidence-based psychoeducational group program designed to help you heal from (not just cope with) your chronic health problems

Filling out this form lets me know you are interested in a free phone consult with me to figure out if this group program is right for you.

Click here to learn more about the MTB Healing Group

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Tell me a little bit about the nature of your chronic health problem(s). *

Tell me as much or as little as you feel comfortable with.

Have you done any diagnostic testing? If so, what have you been told? *

Tell me as much or as little as you feel comfortable with.

What have you done so far to try to solve your problem(s)? *

Be as detailed as you'd like.

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

Anything else you want me to know?

How did you hear about me? *

Check as many as apply.

Word of Mouth

Web search for a psychotherapist

Web search for help with chronic pain or other health problems

Facebook ad

Google ad

Other

Thank you for your interest in the Mind-The-Body Healing Group!

Please note: If you don’t hear from me within 2 days of submitting this form, feel free to call me at 603-988-1334 and tell me you’ve submitted an interest form for Minding-The-Body Healing Group program.