Registration

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

In case of emergency, please provide a person you would like to have contacted: *

First

Last

Relationship with You *

I Have Internet Access *

Yes No

How Did You Learn About This Program? *

Social Media Flyer Friend Other

If other, please describe *

Highest Level of Education *

Religious Preference or None *

Occupation *

Are you currently being treated by a physician? *

Yes No

Are you currently seeing a therapist or counselor? *

Yes No

Have you ever attempted suicide? *

Yes No

If yes above, how long ago? *

Are you considering suicide now? *

Yes No

What is the main reason you want to take this course? *

To improve my mental health To learn more about mental health To better support a loved one Other

If other, please describe *

If you are registering with another individual for the companion price, please list the name of your companion below: *

I recognize this is a mental health education program and is not a therapeutic program and cannot substitute for physicians, professional counselors, or mental health providers. *

I have read and understood the above statement

I understand that attending this educational program does not establish a physician-patient or therapist-client relationship and I will not make medication or treatment changes without consulting my healthcare practicioner. *

I have read and understood the above statement

The community Nedley Depression and Anxiety Recovery Program is a unique educational program that teaches the causes of depression and anxiety. I understand that the program staff are providing an educational service only and I do not hold them responsible for my mental health and wellbeing *

I have read and understood the above statement

Depression & Anxiety Recovery Program Registration

Please read the following statements and check the box beside each statement to acknowledge you have read and understood each statement.

Worship with Us

Follow Us On