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Group Pre-Enrollment
Hi there, please fill out and submit this form for more information about our groups.
7
Questions
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1
What name do you go by?
Nicknames, preferred names, and chosen names here
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2
Name
*
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Your full legal name, please
First Name
Last Name
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3
Email
*
This field is required.
This is for contact purposes ONLY
example@example.com
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4
Phone Number
*
This field is required.
This is for contact purposes ONLY
Please enter a valid phone number.
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5
Prior to enrollment in the group you will be contacted to schedule a short enrollment call to ensure that the group is the best fit for you. Please indicate the best method for scheduling that call
*
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Email
Text
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6
Are you located in the state of New Jersey, New York, or Pennsylvania?
*
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YES
NO
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7
What group are you looking for more information on at this time?
*
This field is required.
Heart Lab: Advanced Non-Monogamy
Heart Lab: Exploring Non-Monogamy
The Tangent Club: ADHD Support Group
The Rest Stop: Chronic Illness Support Group
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