Renew Counseling

Group Participant INQUIRY

Please fill out the following questions so we may get you enrolled in the group starting soon!

First Name*

Last Name*

DOB*

Email Address*

Phone Number*

Home address*

City*

ZipCode*

List any treatment that client is currently receiving, or has received?

What church(s) do you attend (if applicable)?

If you were referred by someone, please list their name below.

Are you a current or past client of Renew Counseling?*

Yes

Group seeking to participate in:

Love and respect (Mondays)

Get out of your head (Tuesdays)

Empowered women (Wednesdays)

Codependency recovery (Thursdays)

Boundaries for your soul (Thursdays)

Stress proof your life (Fridays)

You consent to receive communications from us electronically. We will communicate with you by e-mail or phone. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.