Event Participant
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Please fill out the following questions so we may get you enrolled in the group starting soon!
First Name
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Last Name
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DOB
Email Address
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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
No
Group seeking to participate in:
Finding Freedom From Emotional Eating (Wednesday's at 6:30pm beginning 3/4 with Amy)
Hope After Loss (March 9th, 6:30pm with Omar Ziyadeh)
From Confusion to Clarity (Tues, Mar 24th, 6;30pm)
Healing Trauma after Abortion (English) (Tuesday's at 6:15pm beginning 4/07 with Bertha)
Healing Trauma after Abortion (Spanish) (Saturday's at 8:45am beginning 4/11 with Bertha)
From Burnout to Balance (Wednesday at 6:00pm via zoom beginning 4/29/26 with Karlene Barnett)
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.
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