Anxiety Book Club - September 2022 REGISTRATION
Your sign up will not be complete until payment is submitted. This form is for registration and signing up for a specific time ONLY (and does not include payment). If you have not received an invoice or submitted your credit card information, please contact Lori Wood at Office@ZeinaHalim.com by no later than Saturday, August 27th, 2022.
Which Group will you be attending?
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Thursdays at 11:30am PST (Pacific Time Zone - California USA)
Thursdays at 5:45pm PST (Pacific Time Zone - California USA)
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E-mail for Communication*** Please Add: ZeinaHalimTherapy@gmail.com, Zeina.Halim@NeuroMethodTutoring, and info@NeuroMethodTutoring.com to your contacts so that our emails will not go to SPAM***
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example@example.com
Email for Zoom (ALL MEETINGS REQUIRE A FREE ZOOM ACCOUNT) I will need all of the emails associated with any Zoom accounts that you will use for the book club. You can sign up for a free zoom account at https://zoom.us/signup
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example@example.com
ALTERNATE E-mail for Zoom (IF YOU MIGHT BE USING MORE THAN ONE EMAIL) Again, it is important to have all the emails associated with Zoom when you will be logging on to the book club. If you will be using a partner's computer, for example, and will be using their zoom account, please provide the email associated with that account below:
example@example.com
How did you hear about this Book Club?
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David Burns email
My therapist
Email from Zeina Halim
Friend or Colleague (word of mouth)
Other (If other, please specify where in the next question
If none of the above, please let us know how you heard about the Book Club ...
Are you a therapist?
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Yes
No
If you live in California, are you interested in an anxiety THERAPY group or other therapy groups? (In addition to this anxiety book club)
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Yes, I live in California and am interested in an anxiety THERAPY group or other therapy groups.
No, I am not interested in therapy groups, or I do not live in California.
Do you need to be in an AUDIO-ONLY breakout group? (We require people in most breakout rooms to keep their video ON so everyone feels safe. But if you do not have access to video or for another reason want to have your camera off, you can be in an Audio-Only breakout room.
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Yes, please put me in a breakout room without video. (I understand that this means I may be paired with the same few people over and over again, rather than getting paired with different people each time.)
No - I will keep my video ON during breakout room sessions.
Age Appropriate
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I am 18 years of age or older. (If you are not, please contact ZeinaHalimTherapy@gmail.com to discuss.)
I am under 18 but have permission from Zeina to join.
Mobile Number
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Phone Number
Work Number
I understand and acknowledge that this group is ONLY for education and does NOT provide treatment. I am fully aware that the Anxiety Book Club on the book When Panic Attacks offered by Zeina Halim, starting September 2022, is solely an educational group. This book club is NOT intended to provide treatment for any illness and is NOT an emotional support group. There is absolutely NO treatment contract between myself and Zeina Halim and/or any other facilitators of the group. I agree that no therapist-patient relationship is created by any personal work conducted by Zeina Halim or any of her colleagues and myself while participating in the Anxiety Book Club. I take full responsibility for my own health and indemnify, defend and hold harmless any of the above persons and/or entities (including the parent company, NeuroMethod Tutoring) if I experience any adverse feelings or health during or after this group whether or not they may relate to the group or book in any way. I agree that Zeina Halim, NeuroMethod Tutoring, and any and all of their guest colleagues or associated colleagues, cannot be sued in any court based on their actions, discussions, emails, or any communication with me. Finally, along with the above, I agree that my attendance in this group is ONLY for educational purposes and NOT for treatment. By signing below, I agree to all of the above.
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Zeina Halim and her colleagues value acceptance, inclusion, and equity and believe that those are foundational principles for groups. We understand that the harm of oppression based on identity (e.g. race, ethnicity, gender, identity, sexual orientation, ability status, physical attributes, country of origin, religion, etc.) is real and hurtful. We understand that this kind of oppression pervades the daily life of some members of our community more so than it does others. We ask anyone joining our group the same thing that we ask of ourselves: to be attentive to ways in which privilege you experience may lead to blind spots; to be thoughtful about the impact of your actions, even if well intended; and to received feedback with curiosity and an open heart. By signing below, I agree to these principles.
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My Products
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Full Price Anxiety Book Club
($24 per week for 12 weeks, paid in advance) *******If you can afford the full price of $288, but need to split it into two payments, please pay now what you can below and email Office@ZeinaHalim.com
$
288
Discounted Price of $20 per Week for Anxiety Book Club
($20 per week for 12 weeks, paid in advance)
$
240
Discounted Price of $16 per Week for Anxiety Book Club
($16 per week for 12 weeks, paid in advance)
$
192
Discounted Price of $12 per Week for Anxiety Book Club
($12 per week for 12 weeks, paid in advance)******** If you need an additional discount, please email Office@ZeinaHalim.com
$
144
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