Enroll in Survivor Wellness
Please enroll to participate in programming at Survivor Wellness.
Each individual who would like to participate must enroll separately.

Programming is offered to any individual who has received a cancer diagnosis as well as their family members, loved ones and caregivers (collectively referred to as "cancer survivors").

Once you are enrolled, you are eligible to participate in free programming* at Survivor Wellness.

Please fill in all fields marked with a red * asterisk. 
You may provide other information as well. Your answers remain confidential. 

A Care Coordinator will reach out via your preferred method of contact to learn more about you and your needs, as well as provide more information about Survivor Wellness, our programming, and more.

Most programming is offered at no cost to cancer survivors and their caregivers, including: Group Support, Group Classes, Individual Counseling & Coaching, and Individual Wellness & Therapeutic Services. To ensure equity in free programming, Individual Services are booked based on priority and needs, as assessed by our Care Coordination team.

Please note: only enrolled members who agree to receive emails from Survivor Wellness are eligible to receive the monthly invitation to book free services via the Individual Services Booking Request form. If you elect not to receive email from Survivor Wellness, you will need to contact us directly to receive that invitation.

*Reduced cost services for enrolled members are available from our Wellness Partner businesses, the small businesses owned by the same professionals who volunteer their services for our free programming. Appointments must be booked directly through the businesses, and are delivered at our location. This allows you to book sessions on your own schedule on a first-come, first-serve basis outside of Survivor Wellness programming hours.

If you are unable to fill out and submit this form, please contact our offices: 801-236-2294, or helpdesk@survivorwellness.org

"This place heals the things the doctors cannot." 

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First Name: *
Last Name: *
Date of birth: *
MM
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DD
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YYYY
I identify as: *
My preferred pronouns are:
Phone Number (XXX-XXX-XXXX) *
I can receive text messages at the above number.
*Booking confirmations may arrive via text if "yes". You may opt out at any time.
 *
Email Address: *
May we add you to the Survivor Wellness mailing list?
PLEASE NOTE: To receive the monthly booking request form and other important communication from Survivor Wellness, you must agree to be on our mailing list. You may opt out at any time.
 *
Which Survivor Wellness programs you are interested in joining at this time? 
Please check all that apply.
 
Programing includes:
• Group & Peer Support: Wednesday Night Support Group, Caregivers' Group, Walking Group, Garden Group, Courageous Conversations, Peer Support
• Individual Counseling & Coaching: Mental Health Counseling, Life Coaching, Patient Advocacy
• Individual Wellness Services: Massage Therapy, Reiki, Craniosacral Therapy, Deep Healing Skincare, Yoga Therapy, Individual Sound Bath
• Group Classes: Qigong, Coming Home to Your Body, Group Sound Bath
• And more!

If you are interested in a specific type of programming, please indicate that in the "Other" field.
 *
Required
How did you hear about Survivor Wellness? *
Have you received a cancer diagnosis in your lifetime? Thank you for your answer. *
Are you a family member, loved one or caregiver of a person who has received a cancer diagnosis in their lifetime? Thank you for your answer. *
How would you like to be contacted by our staff to discuss how we can best support you? 
*If you choose not to be contacted, please reach out to us in order to participate in programming.
 *
Thank you for enrolling in Survivor Wellness. We look forward to supporting you.

Please add any comments or questions here.

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