Language
English (US)
Wellness Groups Registration
Information submitted through this form is encrypted and HIPAA compliant.
Name
*
First Name
Last Name
Pronouns
He/Him/His
She/Her/Hers
They/Them/Their
Your Age
*
We do not accept under 18
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Select at least one. A 50% deposit is required for your reservation.
*
Art Group (4 sessions. $150 deposit. $300 total)
Poetry Group (1 session. $75 deposit. $75 total)
Yoga Group (4 sessions. $150 deposit. $300 total)
Sports Psychology Group (4 sessions. $150 deposit. $300 total)
ABA (Please call our office for an individualized intake - 618.861.0370)
Cell Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
-
Area Code
Phone 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
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Month
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Day
Year
Date
Signature
*
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