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WELL-being Group Registration
Hello! We look forward to meeting you! Please complete the information below and we will be in touch.
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Email
*
Your email
Name (First and Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Are you currently receiving any mental health treatment?
*
Yes; outpatient therapy
Yes; day programming
Yes; other level of care
No
Other
Anything else you think we should know:
Your answer
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