REGISTRATION – “MINDFULNESS FOR ANXIETY” GROUP

Join us at our Norwalk office each Tuesday between 6-7pm for our Mindfulness for Anxiety group!

Must be 18 or older to participate.

Participant’s First Name *

Participant’s Last Name *

Participant’s Date of Birth *

Phone Number

Email address

Current or Previous Client

What are your main stressors?

Experience with Mindfulness

Never tried

Tried a few times

Routinely practice

Insurance Carrier

Subscriber ID

Provider Services # (Back of Card)

Upload a photo of your Insurance card (Front and Back)

Maximum file size: 10MB

Please provide any additional information:

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