Divorce Group Work Application

Divorce, Relationships & Rebuilding You

8-Week Guided Intensive Group Application

Thank you for your interest in participating in this group. Completion of this application is required prior to scheduling a 30-minute consultation call.

Participation is based on clinical appropriateness and overall group fit. Please complete all sections below.

Participant Information

Full Name:

Email Address:

Phone Number:

City / State:

Application Questions

1. Where are you in the divorce process?
(Considering Divorce, In Process, or Post-Divorce)

2. What feels most destabilizing or challenging for you right now?

3. What are you hoping to gain from participating in this group?

4. Are you currently working with a therapist?

5. Have you ever been hospitalized for psychiatric reasons or had a suicide attempt?

6. Are you currently experiencing suicidal thoughts?
YesNo

7. Are there any current alcohol or substance use concerns?

8. Is there anything else you would like me to know?

Participation & Confidentiality Agreement

I understand that this group is educational and supportive in nature and does not replace individual therapy.
If accepted into the group, I agree to maintain confidentiality regarding all personal information shared by other participants.

Investment & Payment Policy

If accepted into the group, the full investment of $1,400 is due within 48 hours to secure your place.

Payment is non-refundable once submitted and should be made via Zelle to:
debraalper1@gmail.com

I have read and agree to the Participation, Confidentiality, and Payment Policies.

Signature

Participant Signature:

Date:

Download: Divorce Group Work Application