Faith and Feelings Group Therapy Registration

Faith and Feelings Group Therapy Registration

Register to participate in the Faith and Feelings Christian group therapy program. Please complete all sections to help us understand your background and needs.
Participant Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relationship to Participant*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Faith Background
Church Affiliation
Please briefly describe your spiritual background
Group Therapy Details
Why do you want to join the Faith and Feelings group therapy program?*
What emotions or struggles would you like support with?*
Health & Counseling Background
Have you participated in counseling before?*

YesNo
Are you currently seeing a therapist?*

YesNo
Are there any mental health concerns you would like the facilitator to be aware of?
Consent & Agreements
Signature*
Date*

MonthDayYear
Date
Should be Empty: