Jason Traweek

Men Connecting Application

Thank you for your interest in attending the spring Men Connecting group. This information will be kept confidential.

Name

First Name

Last Name

Email *

Phone *

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###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about this group? *

Payment *

How would you plan to pay?

Payment *

I agree that I will be responsible for full payment of the series, even if I need to miss a session or sessions.

I agree

I don't agree

Participation *

Do you have past therapy and/or group experience? *

Provide some details

Why do you want to be part of this group? *

If the group is "successful" for you, what things might be different in your life when it ends? *

What do you hope to learn about yourself through participation in this group? *

How do you feel about the following? *

I'm able to find meaningful connection with other men

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I'm able to find meaningful connection with my friends, family, and/or loved ones

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I sometimes have difficulty managing my anger with other people

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Text

Thank you for the information. We will take a look at what you’ve provided and get back to you soon about potentially scheduling at short interview.

Austin, Texasjtraweek@live.com

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