Group Therapy Registration
Name:
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
Desired Group:
*
Overcoming Fear: Group Therapy (Virtual) - Wednesdays 6pm-7pm
Teen Group (In Person/Virtual) - Fridays 4:30pm-6:00pm
Couples Therapy (Virtual) -Wednesdays 6:30pm-7:30pm
Will you be using Medicaid for payment?
*
Yes
No
If yes, who is your policy holder?:
Aetna
Anthem
Sentara
United Health Care
Molina
Other
Policy Number
Self-Pay
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next
( X )
Body Positivity: Group Therapy
$
Free
Teen Group
$
25.00
Couples Group
Per couple
$
80.00
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