Group Intake Form

Group Reservation Request

We're glad you're here! Complete this secure contact form. The Group leader may want to briefly connect with you, and will call from the number (312) 772-9796 to confirm your spot. Each group's out of pocket price is $45 per session. For UHC/Optum and Anthem, your insurance benefits will dictate the cost. For BCBS, our office offers a discount on the price per session.
Select all the apply: Please tell us what types of groups you are interested in registering for or receiving general information. Our team and the group facilitator will help you know where they are in the series and help you decide which is right for you.*

Boundaries Group SeriesCodependency Group Series45+ Unstuck Group
About Groups

Group therapy is generally based on a theme or topic. A licensed therapist leads each group, providing input to promote a dynamic experience. Participants will explore the subject matter in-depth and within the safety of a small unit.

Group therapy could be especially helpful to people who would like a more approachable, collaborative, and generally more affordable than individual psychotherapy.

*Groups sometimes use resources that the participant will have to purchase
Name*

First NameLast Name
Are you a current client of Optimum Joy Clinical Counseling?*

YesNo
Email*
example@example.com
Phone*
Your Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Optimum Joy?
Date of Birth*

MonthDayYear
Date
Note on Participation

We stress the importance of the impact of every person's absence, not only for themselves, but also for others in the group. Your voice, and thus what you bring to the group, is missed if or when you do not show up. Please plan to make every effort to show up to group.

If this specific group doesn't feel like something you can commit to at this time, that's okay! Go ahead and submit your information and indicate that you're interested in knowing about a future group.
Can you generally commit to participating in this group's schedule?*

Yes, I hope attend to every weekNo, I have scheduling conflicts in this time frame
What are your reasons for joining the group? And do you have any goals for group participation?
Have you been in a group before?

YesNo
Is there anything you'd like to note?
A 24 hour cancellation policy applies, where if you cancel less than 24 hours before a group the entire fee will be charged to the card on file. If you need to miss a group, please let your facilitator know prior to 24 hours to avoid late cancellation and no show fees.
Insurance Information
Member ID including Alpha Prefix
Group Number
Insurance Contact Provider or Behavioral Health Number (from back of your ID card)
Name of Policy Holder

First NameLast Name
Policy Holder's Phone Number
Policy Holder's Date of Birth

MonthDayYear
Date
Relationship to Policy Holder
Should be Empty:

Group Reservation Request

Insurance Information