Registration for Healthy Minds Group Series

Today's Date *

Participant's Name *

First

Last

Participant's Date of Birth *

I'm filling this request out for *

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 *

Tell us more about your interest in the group(s) you checked above. What are you looking to draw from the experience? *

How did you first hear about our group courses?

Are you currently a patient at IPG? *

What's your therapist's name?

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

Since you are a new client, the fields below are required in order to enter the participant into our software.

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Gender *

Client Marital Status *

Main Phone *