MSAM Event Registration MSAM Event Registration Harold P. Kirby, LCSW, BCD Please choose which event you would like to attend. 6 Week Mindfulness Class starting – TBA OCD support group. Meets the first and third Tuesday of each month. Call Harold at 610-517-3127. Pendle Hill Day Long Retreat -TBA Grief Recovery Support Group Next Group – TBA Name First Last Birth DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Have you previously received any type of mental health services? (psychotherapy, psychiatric services, etc.) Yes No Are you currently taking any prescription medication? Yes No Please list any specific health problems you are currently experiencing that you may need accommodation for in group.What do you consider to be some of your strengths?What do you consider to be some of your weaknesses?What would you like to accomplish out of your time in this group? Δ
