Never Journey Alone- Group Therapy Registration Form

Group Therapy Registration Form

Never Journey Alone, LLC
Name

First NameLast Name
Date of Birth

MonthDayYear
Sex
Contact Number:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
In case of emergency
Marital Status
Emergency Contact:

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Journey to Healing (Truama Psychoeduation and Processing Group for Adults)This Anxiety is Getting to Me!(Anxiety Management group for pre-teens/teens ages 12-15)
Will you be using insuarnce, if yes please provide the following information. 1. Insurance Provider 2. Member ID# 3. Customer service number on the back of card. ***Our office will verify your benefits and inform you of any financial responsibilty before starting services.
Tell us briefly what brings you to this group therapy and what you hope to gain from your group experiece?
Should be Empty: