Group Registration
Welcome to the Vida Clinic and Seek Institute registration form for group therapy and support groups! In order to get you started, please complete the following information and someone will contact you to guide you in next steps.

Vida Clinic and Seek Institute are antiracist organizations that aim to play an active part in the process of healing and systemic change.
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Name of Person Attending Group (First & Last Name): *
Date of Birth of Person Attending Group: *
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Email Address of Person Attending Group:
Beginning the Week of October 18th, we invite you to participate in our adult group therapy sessions, led by our Senior Clinical Staff. Please select the group(s) you are interested in:
We are also offering the following support groups for free of charge. Please select the group(s) you are you interested in:
We are also taking requests for new groups! Is there a group that you would like to see Vida Clinic offer?  Please let us know what would best meet your or your family's needs:
Status of Person Attending: *
Required
Street Address of Person Attending Group: *
City and State of Person Attending Group: *
Zip Code of Person Attending Group: *
Phone Number of Person Attending Group: *
Language of Person Attending Group: *
Language of Family: *
We do not discriminate on the basis of sexual orientation, gender identity or expression. To provide a more respectful and inclusive experience, please provide any additional information you feel comfortable sharing about yourself and your identity.
Gender of Person Attending Group: *
Prefer to Self Describe Gender:
Preferred Pronouns of Person Attending Group: *
How would you describe yourself? *
Required
Prefer to Self Describe Ethnicity:
How did you hear about us? *
Required
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