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Group Therapy Registration Form

Date

First Name *

Last Name *

Street Address *

Apartment, suite, etc.

City *

State *

ZIP / Postal Code *

Email Address *

Phone *

Your Age *

New or former client? *I'm a new clientI'm a returning client

How did you hear about us? *

I would like to register for the following group: *Armed Forces Veterans Therapy GroupLaw Enforcement Therapy GroupTrauma Recovery Therapy GroupDystonia/Blepharospasm Support Group

I'm looking for: *A place where I can healA group of people I can relate toNew skills and tools to cope with my lifeTo get some questions answeredTo process my strong feelingsOther

Briefly describe the reason for your request

How would you like to be contacted for a brief conversation with Dr. Z? *PhoneEmailEither phone or emailThis screening with Dr. Z is a pre-requisite for joining the group. If there's any reason why the group you've chosen may not be a good fit, Dr. Z will recommend some different approaches.

Dr. Mark R. Zuccolo, PhD, LMFT

Counseling, psychotherapy, coaching for individual adults and couples, serving Alpharetta, Johns Creek, Milton, Cumming, Buford, Suwanee, Duluth, Sandy Springs, Marietta, Roswell, and surrounding areas. Online via telehealth, serving all of Georgia.

Bellagio Psychotherapeutics

5755 North Point Parkway, Suite 33
Alpharetta, Georgia 30022

(678) 554 5632
appointments@bellagiopsych.com

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