Registration: Healing Emotional Trauma Group
Thank you for your interest in becoming a member of the Healing Emotional Trauma group!

Please fill out the following form honestly and completely. At this time, we are only able to accept Georgia residents into the group. After submitting your answers, the group leader will contact you to schedule your free 20-minute consultation call.

If you have any questions, please reach out to kelly@sagecenteratlanta.com

Please note that all information submitted in this form is protected according to HIPAA law.
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Name *
First and last name
Preferred pronouns *
Date of birth *
MM
/
DD
/
YYYY
Phone number *
Email address *
Permission to contact *
Please check all forms of communication you are OK with:
Required
Preferred method of communication *
Required
Street Address Line 1 *
Street Address Line 2
City *
State *
Zip Code *
Emergency contact name *
Emergency contact relationship to you *
Emergency contact phone number *
Emergency contact location (city & state) *
I am applying for the Thursday 7:00pm-8:00pm group starting on May 6, 2021 *
How did you hear about this group? *
What do you hope to gain by participating in this group? *
What concerns or questions do you have about being a member of this group? *
Do you have access to a computer or smartphone with a forward-facing camera? *
What is the biggest challenge you are facing right now? *
Have you ever had thoughts of attempting suicide? *
Required
Are you currently receiving any other forms of counseling or mental health treatment? *
If yes, please describe: (e.g. individual therapy, participation in another therapy group, etc.)
Is there anything else you would like us to know about you?
Please list 3 times over the next few days in which you are available for a 20-minute consultation call *
Electronic signature *
Your submission of this form does not guarantee group membership. Membership will be confirmed or denied by contact with the group leader, Kelly Pierce. By typing your legal name below, you are giving your electronic signature stating that the information submitted is true to the best of your knowledge.
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