Fall Friendship Group 2023
Group Therapy October 3rd, 17th & 30th, November 14th & 28th, December 12th
Participant Name
*
First Name
Last Name
Parent or Guardian
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Reason for referring your child for this social skills group
Email
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Preferred Method of Contact
*
E-mail
Cell Phone
Text Message
This group is ongoing for 5 weeks. Please click the weeks you plan to attend:
*
October 3rd
October 17th
October 30th
November 14th
November 28th
December 12th
Insurance Information
Most insurance plans will cover group therapy. Do you plan to use insurance for the group therapy fees?
*
Yes
No
If you are planning to use insurance, please provide the following information:
Insurance Carrier
*
Please Select
Aetna
Amerihealth Administators
Amerihealth NJ
Cigna
Horizon BCBS of NJ
Independence Personal Choice
Independence Administrators
Keystone East
Magellan
Optum/United Behavioral Health
Total Care Network
Quest
Compsych
Other
Member ID Number:
*
Group Number:
If you are not planning to use insurance, please make payment for your group sessions below:
Number of sessions attending
Only make payment if you are not planning to use insurance:
*
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Product Name
Please select the number of sessions attending
$
40.00
Quantity
1
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8
9
10
Credit Card
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