TCA Group Registration

Wellness Groups Registration
Information submitted through this form is encrypted and HIPAA compliant.
Group Schedule and Locations
Name*

First Name Last Name
Pronouns
Your Age*
Select at least one. A 50% deposit is required for your reservation.*

Express Yourself - Art Therapy (5 sessions. $187.50 deposit. $375 total)Mental Performance (5 sessions. $187.50 deposit. $375 totalArt Journaling for Wellness (1 sessions. $32.50 deposit. $65 total)Writing as Balm, Sustenance, Resistance (4 sessions. $130 deposit. $260 total)Relapse Prevention (8 sessions. $200 deposit. $400 total)
Cell Number*

Area CodePhone Number
Email *
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Front - Please take a pic of the front of your credit card. Your information is kept confidential. You may call us during office hours to give us this information if you'd prefer. - 617.861.0370
Back - Take a photo of your credit card
Today's Date

MonthDayYear
Date
Signature *

Clear
Should be Empty:

Wellness Groups Registration