Name *

First Name

Last Name

Phone

(###)

###

####

Would you be interested in participating in a Wellness workshop *

If question 1 is yes or maybe, proceed to questions 2-6.

Yes, definitely

Maybe, I would like more information

No, I prefer individual therapy

What time of day would work best for you to attend group therapy sessions? *

Morning (9 AM – 12 PM)

Afternoon (1 PM – 4 PM)

Evening (5 PM – 7 PM)

What type of group format would you prefer? *

Supportive (peer sharing, emotional support)

Psychoeducational (learning skills/tools with guidance)

Process-oriented (deep reflection and discussion)

A mix of all of the above

Which age group best describes you? *

Teen (13–17)

Young Adult (18–25)

Adult (26–45)

Adult (46–65)

Senior (65+)

Which topics would you find most helpful in a wellness workshop setting? (Select all that apply) *

Depression

Anxiety

Bereavement (Grief and Loss)

Self-esteem and Confidence Building

Stress Management

Relationships/Communication

Trauma Recovery

Life Transitions (e.g., divorce, retirement, new parents)

Young Adults

Trauma informed Yoga

LGBTQIA+

ADHD

Caregivers

Other