Interested

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Hello! We're excited about your interest in working with Flourish Therapy. If you could take a minute to fill in this short form, it will give us a better idea if what we offer will be a good fit for you.

After reviewing the slides above, I am interested in the following services...

Not sure, that's a lot of optionsSignature ProgramSignature Program with Brain RetrainingEMDRCouplesIndividual IntensiveCouples Intensive

I prefer to work with....

A male practitionerA female practitionerI don't have a preferenceA practitioner of color

I identify as...

FemaleMaleNon-binaryPrefer not to say

Physical health conditions

IBS/abdominal pain/frequent GI symptomsHeadaches/migraines/TMJFood allergies/sensitivies/intolerancesFibromyalgia or widespread painNeck/back/pelvic painAutoimmune conditions/chronic infectionsChronic fatigue syndromeInsomniaNone of the above

Are there certain modalities you would like to be utilized in session?

Not sure!Nervous system regulation/polyvagalIFS/parts workAttachment/interpersonal neurobiologyEMDRNeuroscience/brain retrainingSomatic/body workMindfulness

I would like to receive future communications

I agree to the GDPR & CCPA Terms & Conditions

I confirm that I am at least 16 years of age or older

I have read and accept any EULA, Terms and Conditions, Acceptable Use Policy, and/or Data Processing Addendum which has been provided to me in connection with the software, products and/or services.

I have been fully informed and consent to the collection and use of my personal data for any purpose in connection with the software, products and/or services.

I understand that certain data, including personal data, must be collected or processed in order for you to provide any products or services I have requested or contracted for. I understand that in some cases it may be required to use cookies or similar tracking to provide those products or services..

I understand that I have the right to request access annually to any personal data you have obtained or collected regarding me. You have agreed to provide me with a record of my personal data in a readable format.

I also understand that I can revoke my consent and that I have the right to be forgotten. If I revoke my consent you will stop collecting or processing my personal data. I understand that if I revoke my consent, you may be unable to provide contracted products or services to me, and I can not hold you responsible for that.

Likewise, if I properly request to be forgotten, you will delete the data you have for me, or make it inaccessible. I also understand that if there is a dispute regarding my personal data, I can contact someone who is responsible for handling data-related concerns. If we are unable to resolve any issue, you will provide an independent service to arbitrate a resolution. If I have any questions regarding my rights or privacy, I can contact the email address provided.

Thank you for filling out this form. If it looks like we will be a good fit to work together we will contact you to schedule a complimentary Pathway to Healing session! If not, we will let you know and make recommendations accordingly. 🌿

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