Registration Form

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Registration Form

Thank you for your interest in becoming a member of the 6-week group "Mindfulness for Educators". Please fill out the following questionnaire honestly and completely. After submitting your answers, one of the co-leaders will contact you to discuss your membership in the group.

If you have any questions, please feel free to contact us at 678-235-8968 or kpiercecounseling@gmail.com.

Please note that all information submitted in this form is protected by HIPAA law.

Name *

Preferred pronouns *

Date of birth *

YYYY

Phone number *

Email address *

Permission to contact *

Please check all forms of communication you are OK with:

OK to call and/or leave a voicemail

OK to text

OK to email

Required

Preferred method of communication *

Call

Text

Required

Street Address Line 1 *

Street Address Line 2

City *

State *

Zip Code *

Emergency contact name *

Emergency contact relationship to you *

Emergency contact phone number *

Emergency contact location (city & state) *

Which school do you work at? *

How did you hear about this group? *

What do you hope to gain by participating in this group? *

What concerns or questions do you have about being a member of this group? *

Do you have access to a computer or smartphone with a forward-facing camera? *

Yes

Which group are you hoping to register for? *

From 6:00pm - 7:00pm on the following Thursdays: 8/27, 9/3, 9/10, 9/17, 9/24, 10/1

From 7:15pm - 8:15pm on the following Thursdays: 9/3, 9/10, 9/17, 9/24, 10/1, 10/8

What is the biggest challenge you are facing right now? *

Have you ever thought of, planned, or attempted suicide? *

Yes, in the past 2 months

Yes, between 2 months and 1 year ago

Yes, over 1 year ago

Required

Are you currently receiving any other forms of counseling or mental health treatment? *

Yes

Is there anything else you would like us to know about you?

Electronic signature (Type full name) *

Your submission of this form does not guarantee group membership. Membership will be confirmed or denied by contact with one of the group co-leaders: Amber Amick, APC or Kelly Pierce, Counseling Intern. By typing your legal name below, you are giving your electronic signature stating that the information submitted is true to the best of your knowledge.

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