MIM Registration

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Minds in Motion Group Registration

First name*

Last name*

Pronouns

He/Him/His

She/Her/Hers

They/Them/Theirs

Birthday

Month

Day

Year

Email*

Phone

Why do you believe this group is right for you?

What mental health challenges are you currently working through?

Anxiety or excessive worry

Depression or low mood

Trauma or PTSD

Grief or loss

Anger or irritability

Relationship challenges

Self-esteem or confidence issues

Social anxiety or isolation

Emotional regulation difficulties

Self-harm or suicidal thoughts

Substance use or addiction

Disordered eating or body image concerns

Attention or focus difficulties (e.g., ADHD)

Obsessive thoughts or compulsive behaviors (OCD)

Identity exploration (e.g., gender, sexuality, culture)

Life transitions or adjustment challenges

Coping with a medical or mental health diagnosis

Family-related stress

Other

Food Allergies?

Yes

No

Please specify food allergies

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