Safe Haven Group
April 2nd - May 7th, 2024 - Tuesdays - 4pm - 6pm
Participant Name
*
First Name
Last Name
Pronouns
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Cell Phone
*
Format: (000) 000-0000.
Preferred Method of Contact
*
E-mail
Cell Phone
Text Message
Please check the sessions you plan to attend (Cost - $40 each session)
April 2nd - Creating a Safe Haven
April 9th - Telling Your Story
April 16th - Fostering Hope
April 23rd - Hope as a Coping Skill
April 30th - Dear Future Me
May 7th - Phone a Friend/Closing
Most insurance will cover group sessions. 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:
What are you hoping to get out of attending the Safe Haven Group?
If you are not planning to use insurance, please bring $40 to each session. Checks made payable to Willow Wellness Center.
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