The Healing Portal
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Full Name *
Date of Birth *
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Phone Number *
Email  *
Address *
City *
Zip Code *
Ethnicity/ Race *
Emergency Contact Name *
Emergency Contact Phone Number *
  Have you ever participated in a support or therapy group before?   *
  What brings you to this group? (e.g., stress, grief, anxiety, self-esteem, relationships)   *
How would you like the facilitator to support you if you become overwhelmed?   *
Is it okay for the facilitator to follow up with you individually if needed (e.g., check-ins, resources)?   *
Do you understand and agree to maintain group confidentiality?   *
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