Participant Information

Group Participant

Information

Which Group Are You Registering For?

Women's Managing Anxiety & Depression Group: Beginning Oct. 7th Kids Conquering Anxiety Group: Beginning Oct. 5th

Parent/Guardian (if Group Participant is under the age of 18)

First Name Last Name

GROUP PARTICIPANT'S INFORMATION:

Name (If different from above)

First Name Last Name

Age: *

Sex: *

Address: *

City: *

State: *

Zip Code: *

Best Phone Number to reach you: *

E-mail: *

Additional Information/Notes:

Please briefly explain why you are interested in attending this group:

Payment

A one-time payment is required prior to beginning the group and no other payment is required. If for any reason you will not be partaking in the group, you will be refunded the full amount.

Women's Anxiety & Depression Group $ 130.00

Kids Conquering Anxiety Group $ 100.00

Total $ 0.00