Course Registration Form

Name

First NameLast Name
Online Women's Art Therapy group

Please fill out the form carefully for registration. The group will happen weekly via an online platform for around 2 hours per week. The group will have the same members throughout the 9 weeks. In each session, we will have a check in, around 30 minutes to make art. Then Kate will take a screenshot or you can email her an image, so we can look at each other’s art (one by one, led by art therapist Kate Leppard. During this time, if you are not processing your art, you will be witnessing and holding space for the person who is exploring their art). Kate will then ask for feedback or curiosities from the other group members (please be careful not to project your own meaning onto art). We will close the session with a check out. All discussion and art will be confidential and the group is therapeutic in nature. Each week, themes/directives will be suggested, you are invited to make art in response to this in whatever medium you like. Please do not sign up if you cannot commit to at least 5 sessions. Spaces are limited to 4-6 women per 9 week cycle so please sign up early as spaces go fast!
Birth Date

MonthDayYear
Gender
Phone Number

Area CodePhone Number
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Relationship to you
Email of Emergency Contact
example@example.com
Phone Number of Emergency contact

Area CodePhone Number
What is your previous experience of art therapy?
What do you hope to get out of the group?
Do you have any mental health issues or significant things are working through? All answers will be kept confidentially and are useful for the therapist to know.
What are your strengths? What resources you?
Where did you hear about this group?
Are you comfortable with using Zoom and email?

YesNoI have basic knowledge but could use more supportOther
Can you commit to a two hour live session each week?

YesNoI am away some of the datesOther
What time zone do you live in?
Which grou are you interested in?

The Weaving (Sept 2025 or Jan 2026 start)Phases of the moon (Sept 2025 or January 2026 start)The Body as Oracle: Art, Movement & Erotic Knowing (waitlist)Dream group (waitlist)
Which cycle would you like to join?

September 2025January 2026
What days are you available?

MondayTuesdayWednesdayThursday
Can you commit to the Weaving at 5-7pm PST | 6-8pm MST | 7-9pm CST | 8-10pm EST? Please specify another time that works if not

YesOther
Do you agree to pay $25-45 for each session to Kate Leppard for this course via PayPal or e-transfer (Canada or UK)

YesNo
Please specify amount you will pay each week
Please send a Paypal or e-transfer to kateleppard@gmail.com of $30 to secure your place (This will be offset against your first week's payment or returned if you are not accepted to the course)

Done
Do you agree to keep confidentiality for all group members?

YesNo
If you would like to join the mailing list to hear about other courses please enter your email here*
Please type no if you don't want to
Should be Empty: