Heart & Mind Group Registration
Please fill out the form for the person participating. If registering more than one participant fill out the form for each person. At the end of the form there will be a link to schedule a phone call to complete registration. If you are currently a client at Heart & Mind you will receive any additional paperwork needed for the group.

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Email *
Participant's First Name *
Participant's Last Name *
Participant's Date of Birth *
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/
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Parent/Guardian's Name if applicable
Contact Phone # *
Address *
City, State, Zip *
Group you are registering for *
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