Cycle Breakers Group Sign-Up

PLEASE NOTE: Each meeting is $60 out of pocket, no insurance will be billed.

Class can be paid at the time of each class or paid all up front.

253-460-7248
info@integratedtherapynw.com
3560 Bridgeport Way W, Suite 2C, University Place, WA 98466

This form is to become established on the list to participate in the Cycle Breakers Group at Integrated Therapy Services NW. Once the form is submitted, our office will contact you within 5-7 business days.

Cycle Breakers is for Asian American moms who are pregnant and/or have babies up to 18 months.

Group has a March 2025 start date.

The group runs Fridays from 11:00 AM - 12:30 PM.

This is a 7-week, drop-in style, group.

Babies up to 18 months are welcome to join!

Participant Information

First and Last Name

Preferred Name

Date of Birth

Legal Sex

Female Male

Gender Identity

Preferred Pronouns

Contact Information

Phone Number

Email Address

Mailing Street Address

City

State

Zip Code

Are you currently pregnant or have recently given birth in the last 2 years?

Are you currently an ITS client?

If you answered yes to the above question, who is your ITS therapist?

Do you see a therapist outside of ITS?

Do you have any thoughts of harming yourself?

Do you have any thoughts of harming other people?

Do you have any food allergies?

How did you hear about this group?

Additional Questions/Comments/Concerns

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