New Support Groups Being Formed

Please complete this form if you are interested in joining a Cancer Survivor or Chronic Pain Support Group. The charge for the program is $75 and will include 5 support sessions — no more than 12 participants will be in any group. A licensed mental health provider will facilitate each group. (Future group sessions will be determined by the interest of the group members following the first 5 sessions). Please complete this form as soon as possible so that we can schedule sessions and send the actual registration/payment form. Partial scholarships are available.

SPIRIT: Support Group Interest Form

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Group Interest(Required)

Cancer Survivor Group

Chronic Pain

Availability (check as many as are applicable)(Required)

Weekdays (EST)

Weeknights (EST)

Sunday morning (EST)

Comments / Questions