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Chronic Illness Support Group Registration
Weekly Support Group for those Living with Chronic Illness
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Email
*
Your email
Which Day/Time are you joining?
Wednesdays 11am-12pm MST
Wednesdays 5:30-6:30pm MST
Interested in other day or time
Add me on the waitlist
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Date Interested
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Name
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Address
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Your answer
City, State, Zip
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Phone
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Your answer
How did you hear about the group?
*
Friends/Family
Therapist
Facebook
Psychology Today
Email
Flyer
Website
Other
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What interests you about this group?
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To join the group, you will be contacted by South Counseling to get all set up. Cost is $5-$30 per week and is sometimes covered by insurance. How would you like to be contacted?
*
Email
Phone
I'm not able to pay $30 per week, but I could pay
$5
$10
$15
$20
Other:
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A copy of your responses will be emailed to the address you provided.
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