Interest Form • New River Wellness Collective

Please fill out this interest form and someone from our team will be in touch with you soon. **If you do not receive a response from a group member within 2-3 days, please email us at newriverwellnesscollective@gmail.com.**

[We are committed to protecting your privacy. We use HIPAA-compliant communication services, but please do not send private health information or other detailed, confidential information in this form.]

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Thank you for your response. ✨

Name of person seeking services

If you are completing this form to refer someone else, please write your name and relationship to the individual.

Pronouns [of person seeking services]

Age [of person seeking services]

Gender [of person seeking services]

Email address [Provide guardian’s email if the person seeking services is under 18]

Phone number [Provide guardian’s phone number if the person seeking services is under 18]

Choose several options

Email Phone call

Please share what service(s) you are seeking, and provide a brief description of why you (or the person seeking services) are interested in services at this time.

Is there a specific clinician with whom you are interested in working?

How did you hear about New River Wellness Collective?