Well Group Registration Form

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Our groups are here to meet this moment providing accessible, affordable, and affirming care. Please select the group you are interested in joining below. After registration, one of Well's Digital Care Navigators will reach out to finish registration and connect you with your group. Please reach out to care@wellonline.com or call 858-381-3535 if you have any questions! **All groups will begin Monday, May 3rd, 2021.**

First Name *

Last Name *

Date of Birth *

YYYY

Phone Number *

Email Address *

Well currently provides services only to residents of California. Do you reside in California? *

Yes

Which group would you like to join? *

Daily Drop-In Groups (Monday thru Friday, 12:00PM PDT)

Coping with Anxiety + Panic Attacks (Mondays, 4:00PM PDT)

Coping with Grief and Loss (Tuesdays, 4:00PM PDT)

Required

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This form was created inside of wellonline.com.