Integrated Psychotherapy - Group/Workshop Registration Form

If you are sending in registration by mail, please use this form:

NAME OF GROUP PARTICIPANT: ___________________________________________________
AGE OF PARTICIPANT: ____________________ DOB: _________________________________
ADDRESS: ______________________________________________________________________
PHONE: _________________________________ CELL: _________________________________
EMAIL:________________________________________________________________________
GUARDIAN/PARENT'S NAME: ______________________________________________________

Please check the group for which you are registering:

Check	Group Name	Dates	Fee/Cost	Pd CHK/CC
	Mindful Eating for Adults Mondays, 8 weeks	Sept 5 - Oct 24 2011	$160
	Women's Empowerment and Spiritual Growth Thursdays, 10 weeks	Sept 8 - Nov 10 2011	$200
	Parents of Teens with ED Third Monday of each month	check website for times	Free
	Living a Creative and Mindful Life - for Women Mondays, 10 weeks	Jan 9 - Mar 12, 2012	$200
	Recovery and Resilience 10 Weeks	Jan 12 - Mar 15 2012	$200
	Mindful Eating-Mindful Living for Tweens	Jan - Feb 2012	Free
	WHAT... Me Anxious??!! Thursdays, Six weeks	Jan 12 - Feb 16, 2012	Free
	Find Your Own Voice - Teen Girls Wednesdays, Seven weeks	April 5 - May 23, 2012	Free
	College Transitions 4 Fridays, 1-3 pm	July 2012	Free

**All groups are held at Integrated Psychotherapy, unless noted otherwise.

For Minors: If you are registering your teen, please read and sign before sending in this form:
I, _____________________________ (parent of registering teen), give my permission for______________________________ (teen) to participate in the group. I will ensure timely
drop off and pick up after group. I will not hold responsible Integrated Psychotherapy or group
leaders for any injury that my teen may incur while participating in the group.
I will also insure that my teen participates in all scheduled groups.

_____________________________________ (participant's signature)_____________________________________ (parent signature)

FOR ADULTS:
I, ____________________________, agree to attend all scheduled groups. I will not hold Integrated Psychotherapy or group leaders liable for any emotional or physical injury I may incur while participating in this group. I give permission to the group leader to contact my therapist/PCP if necessary.

__________________________________ (participant's signature)

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Please mail registration form to:

Integrated Psychotherapy 31 Hastings Street Mendon MA 01756
Attn: Sherri Snyder, MA, LMHC
or fax form to : 508.473.1226