Polyvagal Theory Applied Yoga 6-week Course

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Registration Form: Wednesdays, 3:30 -5:00pm CST

Email *

Embodied Healing

Email Address *

Name *

Address (Street, City, State, Zip Code) *

Phone Number *

Are you currently participating in psychotherapy? *

Yes

Other:

If you are currently a client at Waypoints Counseling, or have been in the past, please know that you have the option to keep your camera off during the class, to shorten your name on your zoom settings, and to participate on a level at your choosing in order to maintain anonymity. Keep in mind that Erin Evanson-Lass will NOT disclose that you are or have been a client, and that only YOU have the option to disclose this information. By checking the box below, you understand that if you disclose this information on your own, Erin Evanson-Lass nor Waypoints Counseling, PLLC is responsible for that disclosure. *

I have read and understand that my information will not be disclosed by Erin Evanson-Lass/Waypoints Counseling, PLLC.

Required

Will you be participating live or will you be requesting the link post the live class? *

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