Somatic Dialogue Registration Form

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Facilitators

Janet Evergreen, MA
115 RiverBluff Circle, Charlottesville, VA 22902
(434) 906-4181
janet@janetevergreen.com
www.janetevergreen.com

Howie Evergreen
hevergreen1@gmail.com

NOTE: If you are taking this class with a partner, you each need to complete this form individually.

Email *

Name *

Address *

Telephone Number *

Communication Preferences: *

Check if you text message.

Check if you are willing to share your phone and email contact.

Required

Birth Date and Age *

Familial Status (i.e. married, partnered, single, divorced, children, grandchildren...) *

Class Agreements *

Check if you understand this is a somatic-based teaching and experiential inquiry. Acknowledging that you take responsibility for your own mental health and wellbeing during this class.

Check if you agree to uphold confidentiality for this group.

Required

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