Group Art Therapy Registration
Name and/or preferred name
*
First Name
Last Name
Birthday (Add me to the Creative Butterfly Birthday Club)
-
Day
-
Month
Year
Date
E-mail
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do you have any allergies and/or preference of certain scents?
Please Select
Yes
No
If yes, what are they?
Back
Next
Is there anything else you would like me to know about you?
Do you or have you ever experienced any of the following mental health issues?
Anxiety
Depression
PTSD
Complex PTSD
Autism
ADHD or ADD
OCD
Phobias of any kind
Sleep Disorders
Eating Disorders
Acute Stress
Schizophrenia
Bi-polar Disorder
Borderline Personality Disorder
Alcohol or Other Drug Addiction
Grief
Trauma
Other
Payment Options
I will pay upfront for the program ($510)
Weekly payment plan ($85 per week)
Fortnightly payment plan ($170)
Please call me to discuss other options
Casual attendance ($95)
Please Select Workshop Date and Time
*
How did you hear about the program?
Social media
Friend/Colleague
Website
Professional referral
Signature
Submit
Submit
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