Southern Crescent Sexual Assault and Child Advocacy Center -Registration Form
 Adult Therapy Group- Life After Trauma
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Greetings! Southern Crescent Sexual Assault and Child Advocacy Center Counseling Department is creating an adult therapy group to help survivors of trauma to receive support and guidance during their healing journey. Your participation in this group is voluntary. You may choose not to participate. If you decide to participate, you may withdraw at any time. This registration form will take approximately 5 minutes. Your responses will be confidential. If you have any questions about the form, please contact the Counseling Department at 770-603-4045. Thank you! ELECTRONIC CONSENT: Please select your choice below. Clicking on the "agree" button below indicates that: you have read the above information and you voluntarily agree to participate. If you do not wish to participate in the adult therapy group, please decline participation by clicking on the "disagree" button and click submit form. *
First and Last Name
Date of Birth *
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Gender *
Email *
Phone Number *
Please briefly describe your previous history of mental health treatment and current involvement with mental health services at SCSAC-CAC or elsewhere.   *
What is one topic you want to be discussed in group? *
What is your opinion about the opposite gender participating in the group sessions? *
Do you have access to wifi and the application “ZOOM” (for online video sessions)?   *
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