Introduction to Counseling Registration

Introduction to Counseling Registration

Our Introduction to Counseling workshops are free to current members and open to a limited number of attendees each week. After submitting your registration below, you will have reserved your spot for that particular workshop. Please note that each workshop is a two-part series, with each session held one week apart. Attendance to both sessions is highly recommended.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you a current member of Assurance Healthcare & Counseling Center?*

YesNoNot sure
I would like to attend the following counseling workshop...*
Are you attending this 2-part workshop with the intention of establishing with a counselor shortly afterward?
By clicking the submit button below, you agree to have the above information sent securely via this HIPAA compliant form to another third-party application managed by Assurance Healthcare & Counseling Center where private data is securely stored. Any identifying PHI (protected health information) will not be transmitted via email or any other insecure format.
Should be Empty: