Bright Harbor Healthcare

Embrace & Grief and Trauma Center Support Group:

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* 1. Name

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* 2. Group Name:

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* 3. Phone

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* 4. D.O.B:

Date

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* 5. Address:

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* 6. Email Address:

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* 7. Emergency Contact Name & Phone #:

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* 8. What brings you to this group?

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* 9. It is essential for support groups to provide emotional safety and privacy.

I agree that the information shared inside this group is to be treated as private and confidential information.

Please select one of the following options.

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* 10. Electronic Signature:

T