RISE Group - Intake Form
The RISE Dance Movement Therapy Group for Womxn
Registration Date *
MM
/
DD
/
YYYY
Name (first and last) *
Date of Birth (DD/MM/YEAR)
Country of Birth *
Email *
Phone Number *
Occupation *
Which of the following most accurately describe(s) you? (Choose as many as you like) *
Are there any health conditions, diagnosis that the therapist needs to be aware of? *
Do you have the NDIS funding for this program? If yes, please indicate if it is a self-managed, plan-managed or the NDIA managed. *
Is there anything the therapist needs to know about your culture or beliefs that will help her to respectfully support you? *
How did you hear about this group?
Clear selection
Would you like to subscribe to Mioi’s monthly newsletter?
Clear selection
I understand that I will have to pay the fees for my sessions. *
Required
Consent - I consent to my information being collected and stored in accordance with the Privacy Act (1988) and I understand that my consent will continue until I advise Mioi Forster-Nakayama in writing or verbally that I withdraw my consent. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Moving Circle.