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Dissociation Group Registration
Please fill this out to begin the intake process for the Understanding Dissociation Group.
I will email you once I receive the registration form with links for payment and group meeting information.
Name and preferred pronouns
Email
Relationship to the individual with dissociative disorder
Phone
What best describes your gender?
*
Female
Male
Non-Binary
Prefer not to say
Unsure
Not listed here
Referred By (please include name and email of therapist that referred if applicable)
Briefly describe what you hope to gain from participating in this group including specific topics or issues you would like to be addressed.
Is there any other information that you feel would be helpful for me to know before the group begins?
Submit
Thanks for submitting!
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