Anxiety Management Support Group Registration
Register to join our support group and take a positive step towards managing anxiety. Please complete all fields to help us understand your needs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary reason for joining the support group?
*
Have you previously attended any support groups?
*
Yes
No
How would you describe your current level of anxiety?
*
Minimal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Minimal, 10 is Severe
Preferred Session Time
*
Weekday evenings
Weekend mornings
Weekend afternoons
Other
How did you hear about our support group?
Please Select
Friend or family
Healthcare provider
Social media
Online search
Other
Signature (Please sign to confirm your consent)
*
Register
Register
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