Full Name
*
Email
*
Phone
*
I prefer communication by
*
Email
Text
Both
Are you at least 18 years old?
*
Yes
No
What type of experience are you seeking support for…
*
Mental and Healthcare worker burnout.
FOR Social Isolation AND ECONOMIC IMPACT from Pandemic
Bereavement and Grief
Racial violence and trauma
Veteran with PTSD
Abuse: Emotional, physical, sexual
Time Zone
*
PST
MST
CST
EST
Primary Language Spoken
English (conversational)
Spanish (conversational)
All of your information is confidential and HIPAA compliant. Please be advised The Sharing Group is not a psychotherapy or medical modality. The Indra's Net's Team carefully reviews all submissions and approves eligible participants for Sharing Groups. You will receive a text and/or email notification within two business days confirming your attendance and introducing you to your Sharing Group Facilitator upon completion of the review process.
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Gender
*
Male
Female
Nonbinary
Are you actively contemplating suicide?
*
Yes
No
Do you currently have a dependency on alcohol or recreational drugs?
*
Yes
No
Do you currently have a dependency on prescription drugs?
*
Yes
No
Sharing Group Tenant Agreement: Sharing Groups run for 6 consecutive weeks (unless the date falls on a nationally recognized holiday) at the same time and are held via Zoom or in-person, depending on your location and group theme.
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Are you able to participate in Sharing Groups by being timely, with a stable internet connection, a private setting in which others cannot hear the conversation outside of the group, and possess adequate audio and visual equipment to support connection through eye contact and clear voice?
*
Yes
No
Do you understand the Sharing Groups are not psychotherapy or medical treatment, and not intended to replace therapy with a licensed mental health care practitioner?
*
Yes
No
Do you agree to maintaining the confidentiality of each group member and what is shared within the group container?
*
Yes
No
Agreement
*
I have answered the questions on this form truthfully to the best of my knowledge, read and understand the Indra’s Net Sharing Group format, and I fully agree to abide by its terms.