Women's Divorce/Separated Support Group
Please submit the form and payment to register for the group meeting. This meeting is held on Wednesday's 12pm-1:30pm. The group size is 6-8 registered members. The group is held in-person at Janean VeDova Therapy office located in the Ford Building in Portland OR. This form is HIPPA compliant to protect your privacy. 
Email *
First and Last Name, Preferred Name if Different, and Pronouns *
Today's Date *
MM
/
DD
/
YYYY
Email *
Phone *
I am registering for the following session dates and I understand payment is required to complete registration. Please check which dates and payment you are registering for.  *
Required
Please check the box once you have reviewed the document. *
Required
Please check the box once you have completed the form. *
Required
Payment is required to complete registration. Please choose your method of payment *
I understand the risks of unencrypted text and even encrypted email and give permission to Janean VeDova to correspond via text or email.
 *
Required
By signing on the line below: I understand that by submitting this form and payment I am only registered for the meeting dates I marked on this form and registration payment is nonrefundable.
 *
By signing you understand you are only registered and can participate in group if you have completed this registration form, the intake forms/consent and completed payment. 
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Janean VeDova Therapy. Report Abuse
Google Forms