D&D Fall 2024 Campaign Interest Form — Hesed Counseling, PLLC

D&D Social Group Interest Form

Hesed Counseling is planning to host a D&D Social Group this fall. This group will meet 2 times per month. Participation in the group will be self-pay only. No insurance will be accepted. The campaign will be capped at 6 weeks, with a total introductory cost of $150/participant.

Payment plans will be made available as needed.

In order to help us gauge interest and plan for this group, please complete the following questions.

Current clients will be sent a separate interest form. If you are a current client at Hesed Counseling, please do NOT complete this form.

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Parent/Guardian Email

Age of child participating in group

Gender of child participating in group

Would you prefer the group to meet:

(times are approximate)

On a week night (approx. 7-9pm)

On Saturdays (approx. 10am-noon)