WSAG Register — Steven W Shields

Registration Form

Women’s Recovery Group

Note: If you are not currently a client of Steven Shields or James Willhite you will need to come in for a single introductory session prior to the Group. This is so you can meet us, us you, and make sure the group is what you are looking for.

Name

First Name

Last Name

Age

Phone

(###)

###

####

Anxiety Level of Coming to Group

Preferred Method of Contact

Are you currently seeing a therapist or counselor?

Yes

If yes, who is your current counselor and how long have you been in treatment with them?

We will not contact your current counselor without your written consent. However, we do like to work with them as a team for your recovery and will potentially ask your permission to contact them.

What are your goal(s) for participating in this group?

These can be specific or general. We just want to know what your hoping to get out of this group and what you currently need in your recovery process.

Anything else you'd like us to know about you? concerns or questions?

Anything you share here will be kept confidential.