Legal Full Name:
Preferred Full Name (optional):
Email Address:
Your grocery store gift cards will go to this email account.
Age:
Please note this group is for youth 12-24
Would you prefer to have the group materials mailed to you rather than digital copies? If so, please provide your mailing address
(optional)
Have you had any previous support for your chronic pain?
What are you hoping to get out of the group?
(optional)
Do you require any accommodations to make the group more accessible?
(optional)
Is there anything that might be a barrier to your participation in the group?
(e.g., cost for childcare, internet access, other commitments, etc.)
Do you have any specific triggers that you would like to share so that we can be mindful while we're facilitating the group?
(optional)
Is there anything else you’d like us to know, or any questions you have?