Cancer Support Group Application

Name:*
Date of Birth*
Address:*
Phone:*
-
E-mail:*
How did you learn about the group?*
Are you currently working with an individual therapist?*
If yes, what is the reason? (e.g. divorce, empty nest, grief, trauma, depression…)
Have you had experience with individual psychotherapy or group work in the past?*
Have you practiced any creative arts therapies before?*
When did you receive your cancer diagnosis?*
Are you currently receiving treatment for your cancer?*
If not, are you pre-treatment or post-treatment?
Are you currently using any medications, drugs or alcohol that are NOT part of your prescribed cancer treatment? *
Since receiving your diagnosis, what specific, primary feelings or emotions do you carry with you into your day to day living?*
Describe why you would like to be in this group. What would you like to have happen for yourself?*
Signature (type your name)
Date
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