Group & Workshop Registration

Where can we leave you message? Please check all that apply.
Home phone Work phone E-mail

Are you registering with your partner for a group? Yes
Partner’s name:
*Each group participant should fill out a registration form individually.

Name of contact person in case of emergency:

Relationship of this person to you:

Emergency contact phone number:

Do you have insurance? (It is not necessary for you to have insurance to receive services) Yes No

If “Yes”, what type of insurance do you have?
*We accept PPO insurance and can bill your provider directly for some groups.

Please indicate the group you are interested in:
Mind-Body Connection Exploring Parenthood Relaxation Group
Post-Abortion Support STI Support Group 20's Group
Incest Survivors Group Intimate Transitions Midlife Group

Please indicate who referred you to the CWHC Counseling Program:
Self Website Other CWHC Staff Family/Friend Healthcare Provider
Other

What brings you to CWHC for this group, and what are your goals for the group?

Have you participated in a group before? Yes No
If yes, what type and when?

What questions do you have for us about the group?

Are you a current or past volunteer at CWHC? Yes No
If yes, in what capacity and when?

Would you like to be on our mailing list?
(We send out two newsletters a month by email and one letter every quarter by print mail. In addition, we may email information on upcoming counseling groups and workshops.)

Yes, please add me to the CWHC mailing list and email list.
Yes, please add me to the email list only.
No, I do not wish to be on the CWHC mailing list.

Electronic transmission of group registration is private, but we cannot guarantee your confidentiality with electronic transmission. If you are not comfortable submitting an online registration form, please contact the group facilitator to register. You may also fax your form to 773-935-7145 or mail to Attn: Counseling 3435 N. Sheffield Ave Suite 206A Chicago, IL 60657