Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Will your respect the confidentiality of other group members? This includes not sharing personal information outside of the group? *

Yes

Will you agree to respect others rights, boundaries, and communication methods in group? *

Yes

Please click agree or disagree to the next statement, You understand that Krystal Fortney or any Employee of Eden Eman Counseling & Consulting, LLC has the right to remove you from a group at any time if agreement is broken. *

Agree

Disagree