Application for Healthy Minds Group Therapy

Today's Date

Participant's Name

First

Last

I'm filling this request out for

Participant's age

Gender

Your Name

(required if filling out the form for someone else)

What is your relationship to the group participant?

Your Email

Select which group(s) you or your child are interested in joining

Click here to see more information on each group.

Tell us more about your interest in the group(s) you checked above.

Are you currently a patient at IPG?

What's your therapist's name?

Did your therapist suggest joining one of our groups?

You may click submit, and your application will be reviewed and forwarded to the group coordinator.

We’re Excited To Have You!