Counseling Services | Brigette Keane Counseling

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Name:

Address:

Contact Phone Number:

If this is a cell phone, are you willing to receive text updates regarding the group from the therapist:

Yes

No

What group are you registering for:

How did you hear about the group

Therapy

Website

Friend

Other

Emergency contact name:

Emergency contact phone number:

Are you currently in therapy? If yes, please list name of therapist or psychiatrist

Please describe any mental health conditions you have been diagnosed with

Please list any medications you currently take for mental health conditions

What is your goal for attending this group?

I have read and agreed to the terms for group participation

I consent to sharing information provided here.

What is your style of relating to others in a group setting?

Is there anything else you would like your group facilitator to know?

Do you have any previous group experience? If yes, please describe your experience.

Is your attendance mandated for this group?

Yes

No

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Contact us

503-726-9839

appointmentrequest@bkeanecounseling.com

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