Build Your Somatic Toolkit Registration

Full Name:*

Email:*

Date of Birth:*

Phone:*

Address:*

City/State/Zip:*

How did you hear about this class?

Current Client of ECS:*

Yes

Emergency Contact Information:

Contact Name:*

Relationship:*

Contact Phone Number:*

Six Weeks – Six Focuses:
As this is a 6-week long class, you may choose to attend all six classes or just one, or a few. If you’d like to register for your classes at one time, go ahead and mark which ones you may attend. You can also walk-in on the day of, if you are unsure which ones you’ll make. This just helps with planning.

Dates & Themes (Let us know which ones you plan on attending)

Week 1: Oct. 5 – When your energy feels HIGH

Week 2: Oct. 12 – When your energy feels LOW

Week 3: Oct. 19 – When you feel STUCK

Week 4: Oct. 26 – When you need GROUNDING

Week 5: Nov. 2 – When emotions feel BIG

Week 6: Nov. 9 – When you’re not sure what you need

Questions, concerns, or to register over the phone, call our office 610-282-5735 or email [email protected]

Because these groups are therapeutic in nature, each person registering for a group will be expected to sign into our client portal, Therapy Appointment. In Therapy Appointment you will be able to pay for the group, see the class schedule and submit insurance information, if necessary. More information about how to sign in will be sent upon completion of this form. Thank you!