Counselor: Sheila Jalali, Counseling, Mukilteo, Everett, Lynnwood-WA

Filling out this form is optional. Feel free to call or email me if you'd like to talk about counseling groups or other counseling services personally at 425.244.2565.

First Name:

Phone:

Last Name:

E-mail:

Age:

What are you looking for in a group:

Reasons for joining:

What do you hope to achieve by participating in a group:

Available Nights:

	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

Group you would like to join:

	Compulsive Eating Support Group
	Depression Support Group
	Daily Living Support Group
	Other- Please Specifiy: