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Dempsey Center›Registration Forms›Client Registration Form – Non-Maine

NON-MAINE REGISTRATION FORM

Thank you for telling us about yourself. This information is used to help us recommend services to best meet your needs and goals. Please note, you must complete registration paperwork (including an Acknowledgment of Privacy Policy) before you can access Dempsey Center services. All responses are strictly confidential.

I am registering with Dempsey Center because:(Required)

INFORMATION

Name(Required)
Address(Required)
MM slash DD slash YYYY
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If under 18, guardian name:
Email(Required)
You will also be added to our email list, you can unsubscribe at any time
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OK to leave a voice or text message?(Required)
Preferred method of messaging:(Required)
Emergency Contact:(Required)

CANCER PATIENTS ONLY

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Treatment Types:
Select all that apply
month/year
Type(s) and date(s)

I WOULD LIKE INFORMATION ABOUT

One on One Consultations
Types of Classes + Workshops

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Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 9:00 AM - 1:00 PM /
8:00 AM - 4:00 PM (Virtual)
Sat-Sun: Closed

South Portland
778 Main St.
South Portland, ME 04106

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 9:00 AM - 1:00 PM /
8:00 AM - 4:00 PM (Virtual only)
Sat-Sun: Closed

Find Us

Lewiston
29 Lowell Street
Lewiston, ME 04240

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 9:00 AM - 1:00 PM /
8:00 AM - 4:00 PM (Virtual)
Sat-Sun: Closed

South Portland
778 Main St.
South Portland, ME 04106

1-877-336-7287

Hours:
Mon: 8:00 AM - 5:00 PM
Tues: 8:00 AM - 7:00 PM
Wed: 8:00 AM - 5:00 PM
Thurs: 8:00 AM - 7:00 PM
Fri: 9:00 AM - 1:00 PM /
8:00 AM - 4:00 PM (Virtual only)
Sat-Sun: Closed

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212


Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

Donations

Donations may be mailed to:
Dempsey Center
PO Box 277
Auburn, ME 04212


Checks should be made out to the Dempsey Center, please do not mail cash.
EIN Number: 82-1547129

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