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Weekly Dose Group - Interest Form
Let us know you're interested in joining a Divorce Recovery Community Group
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Phone
Your answer
Group Interested in Joining
*
IN-PERSON
ONLINE
Required
How did you hear about the group?
Friend
Therapist/Counselor
Attorney
Internet Search
Brochure or Mail
Social Media
Email
Other:
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If you were referred by an individual, what is their name?
Your answer
Are there any methods of contact that need to be avoided for confidentiality purposes?
*
Phone
Email
N/A
Other:
Required
Kindly list your ex-spouse(s) full name with maiden included.
*
In order to provide you the best support, ex-spouses may not join the same group. Registration will be based on first come, first serve. Thank you for understanding.
Your answer
Would You like to Receive our Weekly Dose of Encouragement Emails?
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