Registration – Sips of Happiness Mindfulness

Name *

First

Last

Preferred Name/Nickname

Email *

Phone *

If you would like to pay a fee (sliding scale $3-$25) to help cover the costs of the group, choose the best option: *

* Many people attending the group are not able to pay a fee at this time. Please come whether or not you can - we want you in the group!

Are you a new participant? *

New participant
Returning participant

If you are a NEW PARTICIPANT and have never attended services at THP, please fill out the following one time form:

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Do NOT Phone

Check this box if you do not want phone calls

Date of Birth

Email

Referred by:

Referred by (Other):

Insurance Plan

Insurance ID number

Veteran, Active Duty or National Guard

Yes
No

Parenting children under 18?

Yes
No

Child Birth Year(s)

Ethnicity

If other ethnicity:

Emergency Contact Name:

Emergency Contact Phone:

Emergency Contact Relation:

What are your goals for receiving services from us?

Thank you for joining us. We’re so glad to have you! Please be assured that none of the information on this form will be shared. We do not bill your insurance. The information you give us will only be used to support outreach to communities and to report in general terms to our community partners.