Please take the necessary time (about 15 to 45 minutes) to complete this secure, confidential form and thoroughly read the informed consent document provided below. Please enable JavaScript in your browser to complete this form.Moms Online Expressive Arts Therapy Support GroupPlease read this Informed Consent agreement then come back to this intake form to complete your registration. Thanks!Your Full Name *FirstLastPhone *Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhich group are you registering for?5 weekly sessions on Sundays from 11-12:30pmDo you have any favored arts practices you would like to engage with?Literary/Poetry/Spoken Word/RapVisual Art/Vision BoardingMusic/SoundMovement/DanceDrama/Role Play/Empty ChairGuided Visualization/Meditation/ImageryInner Child Work/Play/ImaginationEco-TherapyGrounding/Anchoring/Resourcing PracticesWhich topics are you most interested in exploring?Topics could include: self-care, co-parenting issues, decreased social interaction and increased loneliness and isolation, working from home, conflict resolution, coping with ongoing loss and associated feelings of sadness, healthy boundaries and communication skills, managing boredom, increased anxiety and more.How did you hear about the groups? *FacebookCIIS Student ListServWord of MouthEmail from a friendOtherEmergency Contact Name *FirstLastEmergency Contact Relationship to You *Emergency Contact Phone Number *(Copy and paste these in the field below if you live in Nevada County) Nevada County Adult Mental Health Resources Western County, Grass Valley: 530-265-1437 | Toll-free: 888-801-1437 | After hours 24 hour crisis line: 530-265-5811 | Toll-free: 888-801-1437 Truckee: 530-582-7803 Community Beyond Violence: 24 HOUR CRISIS LINE: (530) 272-3467 | All services are free, confidential and non-discriminatory. Suicide Prevention Nevada County Crisis Line: 530-265-5811 or the National Suicide Prevention Lifeline at 1-800-273-8255. Call 911 if a suicide attempt is underway or medically necessary.Emergency Services in location where you are physically located (just in case of emergency during session): *Please include all of the following: Psychiatric Emergency Services Partner and Family Violence Resource Suicide Hotline/Prevention Services Other This is required in case you find yourself in crisis during a sessionPrevious psychotherapy and Group Psychotherapy Experience *YesNoI've received counseling previously but not psychotherapyDates of Previous TherapyAccomodations Requestedplease indicate if you have any special accommodation requestsAny other questions or comments?Please check the box to indicate your consent: *I consent to having this website store my submitted information so the facilitators can register me for this group. I have read, understood and consent to the agreements contained within the informed consent document listed above.Date *Submit