Heart & Mind Group Registration
Please fill out the form for the person participating. If registering more than one participant fill out the form for each person. Once your information is received by the office you will receive an invitation to our client portal (if new to Heart & Mind) where you can set up password protected access to the portal, complete required paperwork and communicate with the group facilitator. If you are currently a client at Heart & Mind you will receive any additional paperwork needed for the group. We look forward to connecting with you!
Email *
Participant's First Name *
Participant's Last Name *
Participant's Date of Birth *
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Parent/Guardian's Name if applicable
Contact Phone # *
Address *
City, State, Zip *
Group you are registering for *
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