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Upon Completion Of The Sign-In Below You Will Be Directed To The Virtual Partner & Spouse Support Meeting!

(if you were prefer to remain anonymous, check the necessary box below, and skip all other questions)
Your email is required to ensure confidentiality and safety for all of our participants. This email will not be used for spam or newsletters that you have not opted in for

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Please Enter The Following:

First Name

Last Name

Cell Phone Number

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Email Address

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Remain Anonymous

Yes

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How did you hear about the group?

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We would like to send you SMS* reminders so that we can keep you updated with future Partner/Spouse Support Group and other Mountainside Events; would you like to receive these reminders?

Yes

*Please note that unencrypted SMS/Texts are not secure forms of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such SMS/Texts may be misdirected, disclosed to or intercepted by unauthorized third parties. You may consent to receive SMS/Texts from us. We will use the minimum necessary amount of protected health information in any communication. By checking the box above, you acknowledge these risks and consent to text messages as indicated by your response.