Group interest Form

Thank you for reaching out!

This is a secure inquiry form for Abdi Patten Therapy. Once we receive your form, we will reach out via email within two business days to discuss next steps.

First name

Last name

Email address

Phone number

Home Address

Date of Birth

I give Abdi Patten permission to contact me via phone or email: Email is reserved for scheduling and administrative purpose only (e.g., appointment coordination, paperwork, or billing questions). Please note that I do not provide clinical support or therapeutic services via phone or email. If you are experiencing a crisis, please contact emergency services or a crisis line in your area.

Yes No

Are you a current client of Abdi Patten?

Yes No

Have you ever participated in group therapy or a support group before?

Yes No

Which time works best for your participation in group sessions? Select all that apply

Saturday 10am-12pm

Saturday 12pm-2pm

Tuesday 6pm-8pm

Consent and Acknowledgment:
By signing this form, you acknowledge that the information provided is accurate to the best of your knowledge. You also consent to being contacted by Abdi to initiate services as outlined in this form.

Abdi Patten uses Hushmail as a confidential, HIPAA compliant email service. You will need to login to a secure portal to view and respond to any emails. This can easily connect to your present email address.

Thank you for completing the Group Interest Form. We will be in touch soon to follow-up upon your request.

If you have additional questions you can email us at info@abdipatten.com.

Your information will be encrypted.