Beyond the Basics
Note: New participants with an outside therapist are required to attend a 50 minute pre-registration intake assessment with one of our providers prior to attending a class. If you have attended a previous module at our practice, you do not have to complete the intake assessment. Current modules are 6 weeks in length.
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Apt/Unit Number, etc
City
State / Province
Postal / Zip Code
Current therapist
*
Please Select
Shelby Salisbury
Alex Elliott
Kim Vay
Lauren Bishop
Jazlyn Bain
Nissa White
Sarah Donnini
Anna Hutchings
Courtney Baldwin
Jane Le Morrissey
Maite Silva
Amy Eisenman
Luke Smith
Marisa Castro
Simon Fragakis
Steven Littrell
Dr. Jim Andrews
Dr. Leah Jones
Dr. Jane Lanier
Dr. Douglas Chan
Avi Wofsy
Dr. Brian Thomas
Dr. Julie Dorney
Dr. David Halverson
Dr. Shamina Henkel
Dr. Cody Browning
I have a therapist outside of PCH.
Name of therapist outside of PCH
*
Outside therapist contact information
*
Indicate the preferred method of contact for your current therapist and include direct phone number and/or email address.
Contact email
*
example@example.com
Contact phone number
*
Please enter a valid phone number.
How did you hear about us?
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Terms and Conditions
I agree and understand that full registration and payment is required to attend class.
I agree and understand that class registration is non-refundable. If I miss any classes or drop out of class for any reason, I will not be reimbursed.
I agree and understand that payment and registration confirmation emails will be sent to the primary email address submitted. Such emails may contain the health information that I submitted.
*
I have read and agree to the above terms
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Payment
Class/Group Selection
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Beyond the Basics: Wednesdays 10:30am - 12pm
$
510.00
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