Creative Writing Therapy Program Registration Form
Register for the creative writing therapy program by sharing your contact details, participation preferences, and scheduling needs. Do not include sensitive health information.
Participant Registration
Participant Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Preferred Pronouns
Preferred Contact Method
*
Please Select
Email
Phone
Text Message
Either Email or Phone
Program Fit and Scheduling
Writing Experience Level
*
Please Select
No prior experience
Beginner
Intermediate
Advanced
Professional
Other
Primary Goals for Joining the Program
*
Build a regular writing habit
Explore creativity and self-expression
Receive feedback on my writing
Complete a specific writing project
Improve confidence and motivation
Connect with other writers
Other
Preferred Session Format
*
In-person
Online
Either
Preferred Meeting Days and Times
*
Monday morning
Monday afternoon
Monday evening
Tuesday morning
Tuesday afternoon
Tuesday evening
Wednesday morning
Wednesday afternoon
Wednesday evening
Thursday morning
Thursday afternoon
Thursday evening
Friday morning
Friday afternoon
Friday evening
Saturday morning
Saturday afternoon
Saturday evening
Sunday morning
Sunday afternoon
Sunday evening
Accessibility or Scheduling Needs
Creative Preferences and Emergency Contact
Writing interests or themes to explore
Self-discovery
Healing and reflection
Memory and memoir
Poetry
Fiction
Nature
Grief and loss
Identity
Other
Genre preferences
Poetry
Short stories
Memoir
Essay
Journal writing
Flash fiction
Script writing
Other
Emergency contact name
*
First Name
Last Name
Emergency contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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