Althea Therapeutic Services - Holiday Survival Kit: Art Therapy Group Workshop Sign-Up Form

First Name*

Last Name*

Contact information

Preferred Name (if different from above):

Pronouns

Phone number *

Email *

Birth date *

Emergency Contact

Name *

Phone Number *

Relationship *

Sign Up Date(s)

Which group(s)/date(s) would you like to sign up for? *

Please answer this question.

Additional Information

What is your main reason for signing up? *

What are you hoping to gain from this experience? *

Have you ever participated in art therapy prior to this? If so, how was your experience? *

NoYesNo

Do you currently have any concerns about suicide? *

NoYesNo

Rate your concern of suicide on a scale of 1-10. *

Do you have any allergies or intolerances to any materials? (ie. chalk dust) If yes, please describe. *

NoYesNo

Is there anything else you would like us to know prior to the group?

Payment information

Card Number

Expiration Month

Expiration Year

CVV Number

Card Holder Name

Please note that there are limited spots available on a first-come-first-serve basis. Your form will be reviewed by the therapist and you will receive an email with a consent form and confirming your spot in the group as soon as possible. Payment will be taken upon confirmation using the card provided.

Holiday Survival Kit: Art Therapy Group Workshop Sign-Up Form

Thank you for requesting a spot in our Holiday Survival Kit Art Therapy Group Workshop!

The information has been received and we will review it and respond as soon as possible. Should you have any questions or concerns feel free to reach out via email or book a free phone consult!

Thank you for requesting a spot in our Holiday Survival Kit Art Therapy Group Workshop!

The information has been received and we will review it and respond as soon as possible. Should you have any questions or concerns feel free to reach out via email or book a free phone consult!

Contact information

Emergency Contact

Sign Up Date(s)

Additional Information

Payment information

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