Hands Over Fear Registration

Full Name:*

Email:*

Name of Child/Teen Participant:*

Name of Adult Mentor & Relationship to Child (parent, guardian, mentor):*

Date of Birth of Child Participant:*

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:*

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

Because this group is therapeutic in nature, each person registering will be sent a sign-in to our client portal, Therapy Appointment. In Therapy Appointment you will be able to pay for the group and submit insurance information, if necessary, or you may call the office at 610-282-5735.

For groups requiring pre-registration, no-shows or cancellations less than 24 hours will be charged the cost of the group.

Thank you!