Confidential Contact Information Form
In order to participate in meetings, you will need to complete this registration process. Please rest assured that all information you provide will be kept confidential. It will be kept in a secure location and will not be shared with anyone else. We ask for this information in case of an emergency.

Fresh Hope + Mental Health Strong support group meetings are not intended to be a substitute for professional treatment.
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Email *
Full Name *
Email Address *
Date of Birth *
MM
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DD
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YYYY
Address *
City *
State *
Zip/Postal Code *
Country *
Phone Number *
Disclaimer of Liability *
Fresh Hope + Mental Health Strong meetings are not intended to replace professional treatment such as therapy and prescription medication when necessary. Fresh Hope serves as a complementary support and peer information system so that members/partners and those who love them can develop tools to help them achieve wellness with their illness on a daily basis, in order to live with dignity and hope in Christ.
Required
Who can we Contact in case of Emergency? *
  • Name and Relationship to you
Emergency Contact Phone *
Emergency Contact Email *
Do you have a diagnosis or do you have a loved one with a diagnosis? *
What's the Name of the Diagnosis? *
Electronic Signature: Please Type your Full Name *
Submit
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