Community Healing Pod Sign-Up
Contact us for more information at booking@karibumentalhealth.com
Sign in to Google to save your progress. Learn more
Email *
Legal Name (First, Last) *
Preferred Name (optional)
Pronouns
Phone Number (call/text)
Have you done group therapy before?
Clear selection
Are you currently a student? *
Which Pod are you interested in? (select all that apply) *
Please be aware that start dates for our Community Healing Pod will be confirmed once the Pod reaches its full capacity. Pricing details will be discussed and confirmed upon your registration confirmation. Direct Billing requests are subject to specific terms and conditions.
Required
By submitting this form, you agree to be contacted by a Client Care Coordinator to confirm your registration and provide further details about the offering.
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Karibu Mental Health Network.

Does this form look suspicious? Report