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Healing Her Group Therapy Interest form
Thank you for choosing Healing Her, LLC to walk with you on your journey. Please use this form to select your group of interest and to tell us a little more about yourself. Groups will begin January 2024! 
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Today's date *
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Name *
Date of birth *
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What is the best email for you to receive documents and communication to? *
Which state do you reside in? (We are only licensed in D.C., Maryland and Virginia. If you live outside of these states, you will be assigned to our coaching Healing Her groups). *
Which group would you like to join? *
How soon would you like to start group therapy with Healing Her, LLC?  *
What are you hoping to gain from this group? *
Confidentiality of our clients is very important to us. Do you agree to maintain confidentiality for the duration of and after the group has commenced? *
Do you have a history of suicidal or homicidal ideations?  *
Are you currently in therapy? *
Have you done group therapy before? If so, how was that experience for you? *
Who is your insurance provider? (Although Healing Her does not accept insurance at this time, this information will help us to determine which providers present the most need) *
Is there anything you would like me to know? *
Healing Her, LLC services are self pay at this time. Do you agree to place an active/valid card on file for payment? We use a HIPPA compliant platform and your personal information will be protected.  *
How did you hear about us? *
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