Affirmations Holding Space Therapy Interest Form

Holding Space: Affirmations is offering a new, fully virtual therapy group focusing on healing, processing and growing from trauma, anxiety and depression.
The goal of this group is to provide a safe, affirming and supportive environment, facilitated by mental health professionals, to share struggles, gain insights and learn tools to help with personal growth and healing. This group will meet weekly on Mondays from 5:30pm-7:00 pm through a virtual platform (internet access will be needed to participate), starting on October 6th and ending November 24th. This is not a support group and will be a mental health service covered by insurance. For those without insurance, a sliding fee scale is available. This is a closed group and regular attendance is expected. Please fill out the interest form and you will be contacted by an Affirmations staff member to learn more about the group and complete any necessary documentation. The deadline to register is September 29th, 2025.Please complete the following fields and we will be in touch!

*Please note that this is an interest form, and does not guarantee acceptance into the group*
Name*

First NameLast Name
Pronouns*

She/HerHe/HimThey/Them
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Is it okay to leave a detailed message stating that someone from Affirmations is contacting you?*

YesNo
Email*
example@example.com
Preferred Method of Contact*

PhoneEmail
Will you be using insurance? If yes, please provide the name(s) of your insurance provider(s) and specify if it is commercial, Medicaid, Medicare, or a combination. If you have multiple health insurance plans, we will need details for each one. Additionally, please send pictures of all insurance cards before we proceed.*
Insurance member number or ID number*
Is there anything else that you think we should know or that we should keep in mind?
*PLEASE READ*

Next Steps: You will receive an email for an online therapy portal system called "Simple Practice" in 5-7 business days. Forms MUST be completed to gain access to an assessment for group participation. If portal forms are not fully completed we cannot place you in our group.
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Holding Space: Affirmations is offering a new, fully virtual therapy group focusing on healing, processing and growing from trauma, anxiety and depression.

*PLEASE READ*

PLEASE READ