Women of Divorce Recovery Group
Coming Soon: A Divorce Recovery Group for Women! In an effort to gauge the need and interest, as well as manage a waitlist, we ask you to complete the form below.
Interest Form
Note: Completing this form does not guarantee you a spot in the group. Submissions will be reviewed and approved in the order they are received. More information, including Dates/Schedule and Pricing, to be announced with enough interest.
By checking the box below, you are confirming that you are requesting a spot in the Women of Divorce Recovery group for yourself:
*
Yes, I am interested in this group and can confirm I am completing this form for myself.
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Have you been a client/patient of HeartLife (past or present)?
*
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
How did you hear about this group?
Submit
Should be Empty: