Name of the person completing this form *

First Name

Last Name

Phone number of the person completing this form *

(###)

###

####

Groups *

Which group(s) are you interested in (you may choose more than one)

Women's Divorce Group

Please select all that you would be available to attend: *

Mondays 10am-11:30am - Virtual

Mondays 10am-11:30am - In Person Corte Madera

Mondays 6:30pm-8pm - Virtual

Mondays 6:30pm-8pm - In Person Corte Madera

Tuesdays 11am-12:30pm Virtual

Tuesdays 11am-12:30pm In Person Oakland

Tuesdays 6:30pm-8pm - Virtual

Tuesdays 6:30-8pm - In Person Oakland

Thursdays 6:30-8pm - Virtual

Thursdays 6:30-8pm - In Person Corte Madera

What symptoms or challenges are you hoping to address? Select all that apply to the youth during the past 3 months.

Anxiety or excessive worry

Panic / panic attacks / fears

Depressed mood

Isolation

Extreme or rapidly changing emotions

Anger

Aggression

Thoughts of suicide (if you are at imminent risk, please use crisis resources or dial 911)

Non-suicidal self-harm

Friendship / relationship problems

Family relationship problems

Inattention / distractibility

Hyperactivity / impulsivity

Eating disorder

Trauma or significant stressor

Substance abuse

Obsessive thoughts

Repetitive behaviors

Poor social skills

Developmental delays that impact current functioning

Autism or autistic-like behaviors

Co-parenting concerns

Communication

Are you currently in individual therapy?

No

Yes - with a Bridge to Bridge provider

Yes - with a provider from outside Bridge to Bridge

Have you been treated in any of the following settings (check all that apply)? *

Medication management with a psychiatrist

Previous psychotherapy

Intensive Outpatient Programs (IOP)

Partial Hospitalization Programs (PHP)

Psychiatric hospitalization

Residential Treatment

None of the above

Are you insured by Medicare?

Yes

No

Where in the divorce process are you? *

Pre divorce - still contemplating and/or preparing to file for divorce

In the middle of divorce - working on settlement and/or trial

Post divorce - received judgment of dissolution