Group Counseling Survey Name * Name First Name First Name Last Name Last Name Email * Phone * 1st Choice of Day and Time * Monday after 1 pmMonday 6 pmMonday 7 pmTuesday morningTuesday afternoonWednesday 6 pmWednesday 7 pmThursday morningThursday afternoon starting at 3 pmThursday 6 pmThursday 7 pmFriday morningFriday afternoonSaturday morningSaturday afternoon 2nd Choice of Day and Time * Monday after 1 pmMonday 6 pmMonday 7 pmTuesday morningsTuesday afternoonsWednesday 6 pmWednesday 7 pmThursday morningThursday afternoon between 3 – 5Thursday 6 pmThursday 7 pmFriday morningFriday afternoonsSaturday morningSaturday afternoon Size and Length of Group * Small Group (3 – 4) – 1 hourLarge Group (5+) – 2 hoursNo preference Topics That Interest You Depression Anxiety PTSD / Trauma Codependency Relationship Issues Stress Addiction Other (Specify in notes) Anything else you want me to know (including 2nd option for date/time) Submit If you are human, leave this field blank.