Support Group for Black Women

This group is to explore the experiences and identity of being a Black woman in various spaces. You may be feeling stressed or anxious and find that friends, family, or close acquaintances just don’t understand. This group is for women that need support but are not in traumatic situations or currently in crisis. You may be seeking support for daily stressors from your life, relationships, society, or work. It's a good fit if you are overwhelmed with the impacts school, parenting, peers and romantic relationships or the intense racial climate. This group is not a good fit if you are in a state of crisis, have been diagnosed with moderate to severe depression, have a mood disorder or personality disorder diagnosis, or if you have an ongoing, untreated mental challenge or illness that is not being treated by an individual licensed professional.

If you still have questions please contact me at 770-294-4006 or want more information about the group please visit the group page:Empowered Circle Support Group for Black Women

NOTE: This is a new group that is actively being filled. Once the minimum number is reached, all accepted participants who responded will be emailed with further information and your client portal will be set up.

Name*

First NameLast Name

E-mail*

example@example.com

Phone Number

I understand that this group is for black women. (Please stop here if you are not a black women and reach out to see if we have another group that can accommodate you.)*

YesNo

Have you ever participated in a support group before? If yes, what was that experience like? Was there anything in your previous you were concerned about?*

Do you feel comfortable sharing and listening to others in a group setting? This is important as you will be apart of an online support group.*

YesNo

Are you currently seeing a therapist or counselor?*

YesNo

Have you been diagnosed with any mental health conditions that require ongoing, individual treatment (e.g., severe depression, PTSD, or a personality disorder)?

YesNo

Have you experienced any recent mental health crises (e.g., hospitalizations, suicidal thoughts) that might require more focused individual care?

YesNo

I understand this group is offered weekly and online. I am willing to make the required 10 week minimum commitment to attend the group.*

Yes, I understandNo, I can't make the minimun commitment

Are you able to commit to maintaining confidentiality and respecting the boundaries of others in the group? (This is critical in maintaining trust, connection, and rapport in the group.)*

YesNo

Are you available to attend all group sessions at the scheduled time?*

YesNo

I understand the rate for this group is $95 per session.*

YesNo

I understand that this group is a support group that is not covered by insurance and I will have to pay out of pocket. I understand I can use my HSA/FSA funds and any debit or credit card.*

YesNo

I understand that I am signing up for this group but I am not in the group until I have set up my client portal and have completed all my paperwork.*

YesNo

Do you have access to a private and quiet space with a stable internet connection for online sessions? (You can participate where it is convenient for you as long as you have privacy, not in a moving vehicle, and can help maintain your confidentiality and others in the group.)*

YesNo

I am ready to get be a part of this safe space and understand that I will be enrolled in the group. Please look out for all emails once your client portal is set up*

Yes, I'm readyNo, I'm not ready

Date of Signature*

Date

Signature: (By signing this form I understand that I am being considered for group enrollment and that once accepted I still need to complete all paperwork to gain access to the group.) *

Please leave any questions, suggestions, or concerns yo can leave them here or contact me at 770-294-4006. For more information about the group, please check out the group page.

Support group for Black Women