Group Registration Form

MMHETX Group Registration Form

Complete the form and to register for group!
Name*

First NameLast Name
Address * we only need your address to validate you are a Texas resident for group therapy or in the US to participate in workshops. We will not mail anything to your home, unless you ask us to communicate with you via postal mail**

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
I prefer for you to contact me by:*
I am interested in:
I would like to be added to the MMHETX newsletter to receive updates and resources. The newsletter will have resources to support moms and send out updates for any upcoming events in our community. Our newsletter will be quarterly.
I understand that although I am submitting this interest form, I am not a therapy client of Maternal Mental Health of East Texas or its staff therapists. This form is only to indicate my interest in groups and workshops. Someone will contact me after I submit this form to discuss joining a group and will get further information. MMHETX will not share the information you provide.
One of our staff therapists will reach out to you about the group you selected and answer any questions you may have! Please do not hesitate to contact us by phone call/text at 903-805-0531 or email melodye@mmhetx.com. Thank you so much!
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MMHETX Group Registration Form