Group Intake Form

We need some information from you.

Please fill in the required fields below.
Name*

First NameLast Name
Is this your legal name also your preferred name?*

YesNo
What is your preferred name?*
What is your date of birth?*

MonthDayYear
What is your current address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your phone number?*
Please enter a valid phone number.
What is your email?*
example@example.com
Why do you want to join the group?
New diagnosis, life events, etc.
What time work best for you?

Morning (8:00 AM - 12:00 PM)Afternoon (1:00 PM - 5:00 PM)Evening (6:00 PM - 9:00 PM)
What day work best for you?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Insurance Section

Sometimes your insurance can cover group therapy!
Would you like to use your health insurance benefits + coverage?*

YesNoI Don't Have Insurance
Would you like to upload a picture of your card?*

YesNo
FRONT OF INSURANCE CARD
BACK OF INSURANCE CARD
Ensure the card is clearly visible and easy to read.
What is the name of the insurance you have?*
number 1 on the graphic below
What is your ID Number?*
number 2 on the graphic below
What is the Group Number?*
number 3 on the graphic below
What is the Customer Service Phone Number on the card?*
number 5 on the graphic below
Please verify that you are human*
Should be Empty:

Let's get started.