SMR Counseling Services Group Sign-Up Form
Please use this form to share your desire to join one of our groups.  

Please note that there will also be an intake packet that will be sent to you at a future date.

For more information about our groups, please go to our website.
Email *
Type of Group *
Name of Client *
Date of Birth *
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DD
/
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Current age *
Name of Parent/Guardian *
Parent/Guardian's Email Address *
Parent/Guardian's Phone Number *
Does the client have siblings?  *
Number of siblings (# of girls, # of boys) *
What is the clients birth order?   ____ out of ___children *
Who primarily raised the client? *
Issues you would like to address in group counseling: *
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