IFS Zine Group Participant Registration Form
Hello and thank you for your interest in the IFS Zine Group at Radical Healing! This group will begin on March 2nd, 2024 and meet for 6 total weeks on Saturdays from 6pm-8pm (the group will not meet on March 23rd for "spring break"). This group will meet in person at Radical Healing's Movement Space, located at 2007 Chapel Hill Road in Durham, NC.

We are excited to do this needed work in our community. If you're interested in being a group participant, please complete the following form. Please note that completing this form does not automatically guarantee your participation in the group - this form is designed to help you let us know your interest in the group, give us more information about you, and save you some time filling out paperwork later in the event that you do become an official group participant.

Since this form is transmitted electronically, confidentiality cannot be guaranteed. If there is any question you prefer not to answer, please let us know by completing the last form response and we can schedule a time to meet with you over the phone or in person.
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Full Name (first and last) *
Legal Name (if different)
Pronouns *
Required
Race/Ethnicity (This question helps us ensure we create safe-r healing environments by ensuring we have a diverse community represented in our group.) *
Required
Date of Birth *
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Phone Number *
Address *
Email *
Emergency Contact (Name, Relationship, Phone #) *
Do we have your consent to...(the more options you select, the easier it is for us to get in touch with you!) *
Required
How did you hear about Radical Healing and/or this group?
What are you hoping to learn or gain from experiencing this group?
This group will meet in person at Radical Healing's Movement Space, located at 2007 Chapel Hill Road in Durham, NC. Due to the content and format of the group, there will be no option to join virtually. Do you expect that you will be able to attend sessions in person at this address? *
What concerns do you have about potentially participating in this group?
Have you ever participated in a counseling group or mental health skills group in the past?
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If yes, briefly explain
Are you currently seeing an individual therapist? If not, have you seen an individual therapist in the past? If yes, please provide the full name of your current therapist. *
Do you currently experience the urge to self-harm (cutting, scratching, hitting, burning, etc.) and/or engage in self-harm regularly? Have you had these urges or engaged in self-harm within the last year? *
Do you currently and/or within the past year experience suicidal thoughts that include plans and intention on acting out those plans?  Have you had any suicide attempts in your life? (If you wish to answer this question in-person with the Groups Coordinator instead of on this form, please say so.) *
Do you currently and/or within the past year experience urges to physically harm others and/or have you acted out physical aggression towards others? *
If you do experience/have experienced any of these urges, what coping skills do you use to manage your mental health? Who do you have in your support system and how do you engage that support as needed? 
Please indicate whether you can afford to pay the full fee ($45 per session), or if you would like to be considered for financial assistance. We have limited assistance that we can offer to folx who would otherwise not be able to participate. Please note that paying the full fee allows for us to be able to offer this assistance to others. If you'd like financial assistance, please indicate how much you can afford to pay per group session. *
If paying the full fee, there are two options for payment: you can pay for each session individually, or you can pay for all sessions in advance/on the first day your group meets and receive a 10% discount (called our "tuition" option). If you utilize the "tuition" option, we are reserving the space for you throughout the duration of our entire group and if you miss a group session for any reason, including illness, there will be no refunds issued. This is to help ensure our facilitators are compensated fairly and our space can continue to be maintained and used.
By putting your initials here, you are acknowledging that regardless of what payment method you select, you have read and understood this information.
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Do you think you can commit to meeting once a week for 2 hours on Saturdays, for 6 total weeks?  If not, what are some hurdles that may get in the way? *
Do you have any accessibility needs or other considerations that can make the environment more conducive to your involvement? Please include allergies if applicable.
Do you have any medical conditions that may require emergency support during group participation that we should know about? (E.g. allergies that may warrant an EPI-pen, potential seizures, etc.)
If you have general questions for the facilitators or other information you would like for us to have, please use the space provided below.
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