April Hearts Mending Together Registration Form

This 8-week group will meet virtually every other Wednesday beginning April 9, 2025 from 6:00 PM to 7:30 PM.

The self-pay to participate is $40 per session. Some insurances are accepted. A good faith estimate is available for those facing financial hardship. Please contact the office at (855) 969-7877 to receive a good-faith estimate.
Date

MonthDayYear
Date
Participant Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Preferred Contact Number*
Please provide a brief description of the loss experienced and any specific goals for joining the group.*
This is an 8 Week Group. Please confirm availability for the full 8-week group*

YesNo
Preferred Payment*

Pay in full ($320)Session by Session ($40 each session)Need to Discuss Reduced fee due to Financial Hardship
How did you hear about the group?

Company WebsiteWord of MouthPsychology TodayFacebookOther
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