Participant's Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Confirmation *

I understand that, by completing this form, I am indicating my interest in participating in the next round of this workshop. I acknowledge that joining the waitlist does not guarantee me a spot in a group. I also understand that, prior to enrollment, the group's clinician will conduct a brief intake to ensure that it is a proper fit. For individuals who are new to the practice, a lengthier intake assessment will be needed to determine group eligibility. My signature does not serve as commitment to participate in the group, nor does it serve as authorization to charge my credit card. Rather, I will be contacted when the next round is becoming available, at which point I will have the opportunity to register formally, pending eligibility.

I agree