Group Therapy Request
This form is for those requesting a spot in one of our current or upcoming groups. Completing this form does not guarantee you a spot in the group. Submissions will be reviewed and approved in the order they are received within 24-48 hours.
I am requesting a spot in a group for:
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Myself (adult)
My Child (minor)
I am requesting a spot in a group for:
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Myself (adult)
My child (minor)
Group Name:
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Please Select
*WAITLIST* Little People, Big Feelings (ages 4-7)
Group Participant's Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Age
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Date of Birth
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-
Month
-
Day
Year
Date
Grade Level
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Allergies
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Please list any specific concerns around client's mental health or ability to mange emotions:
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What do you hope to get out of this group?
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Is the registering client a current or past patient of HeartLife?
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Yes
No
Who was/is the treating therapist?
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Are you comfortable signing a release for us to speak with this therapist?
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Yes
No
Parent Information
Mom's Name
*
First Name
Last Name
Mom's Phone Number
*
Please enter a valid phone number.
Mom's Email
*
example@example.com
Dad's Name
*
First Name
Last Name
Dad's Phone Number
*
Please enter a valid phone number.
Dad's Email
*
example@example.com
Marital Status:
Married
Separated
Divorced, joint custody
Divorced, one has decision-making authority
Widowed
Emergency Contacts
Emergency Contact #1
*
Phone Number
*
Please enter a valid phone number.
Emergency Contact #2
*
Phone Number
*
Please enter a valid phone number.
Payment is due the day of the first group session. By signing below, you agree to pay for the group in full at the start of therapy OR you agree to contact the front desk if accommodations must be made prior to group beginning.
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Submit
Should be Empty: