The Daring Way Group Registration

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Please indicate the group you are registering for* This field is required.
Rising Strong™
Daring Greatly™
2
How did you hear about this group?* This field is required.
3
Name of participant* This field is required.
First Name
Last Name
4
Date of Birth of participant* This field is required.
Date
Year
Month
Day
5
Email* This field is required.This is where your receipt and registration confirmation will be sent, as well as any group updates
example@example.com
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Cell Phone Number of participant* This field is required.
Area Code
Phone Number
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Address of participant* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Would you like to be included on our email list for future events?* This field is required.
YESNO
9
Emergency Contact Name* This field is required.
First Name
Last Name
10
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
11
Have you ever seen a mental health professional? psychiatrist, psychologist, marriage and family therapist, social worker, counselor, etc
YESNO
12
When did you seen a mental health professional?
13
Briefly list the reasons and outcomes of your experiences with the mental health professional
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14
Do you have a therapist you could work with if something came up in the workshop requiring individual/couple attention?
YESNO
15
Would you like referrals to therapists that could help you work with things that could potentially come up throughout the workshop?
YESNO
16
Are you currently taking any medications for mental health issues?
YESNO
17
Please list the medications and reasons for the medications you are taking for mental health reasons
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18
Are you in recovery from substance or alcohol abuse?
YESNO
19
How long have you been sober?
20
Please provide a brief description of the treatment and support you receive for maintaining sobriety
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21
Do you have a history of eating disorders or disordered eating?
YESNO
22
Please provide information on the support and treatment you are or have received regarding the eating disorder or disordered eating
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23
Have you experienced distressing life events, such as trauma, loss, etc., that have significantly impacted your functioning and quality of life?
YESNO
24
How have you addressed the issues you have faced as a result of your distressing life events?
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25
What sparked your interest in our workshop?
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26
What would you like to accomplish as a result of attending our workshop?
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27
Do you have previous experience with group therapy or a support group?
YESNO
28
Please list the names and dates of any previous group therapy or support groups you have attended.
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29
How were the previous groups you attended helpful for you?
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30
What difficulties did you have with the previous groups you have attended?
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31
Do you have any concerns about participating in a group experience?
YESNO
32
What are your concerns about participating in a group experience?
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Ok
33
How would you respond, as a group member, if someone in the group dominated the discussion?
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34
How would you respond as a group member if someone never participated in the group discussion?
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35
What else would you like us to know about you?
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36
How will you pay for for your group fees?* This field is required.
SELF-PAY - Your credit card will be securely placed on file with Family Strategies and will be charged on the first (1st) of each month. A current credit card MUST be kept on file unless other arrangements are made with, and approved by, the Family Strategies billing department.
THIRD-PARTY PAYER - If you have a previously arranged-for third-party to pay your group fees, they will need to complete the "Third-party Payment Agreement" form and return to the front office BEFORE the first night of group. IT IS YOUR RESPONSIBILITY TO BE SURE YOUR ACCOUNT STAYS CURRENT. If your fees become 60-days past due, you will be contacted and your credit card on file will be charged.
BCBS INSURANCE - If your coverage is a deductible plan and you have not yet met your deductible, your card will be charged on the fifteenth (15th) day of each month until your deductible is met. Once you meet your deductible, you will be charged your co-insurance amount only. If you have a co-pay plan, your card will be charged your monthly co-pay on the fifteenth (15th) of each month. Please add BCBS Insurance information below.
AETNA INSURANCE- If your coverage is a deductible plan and you have not yet met your deductible, your card will be charged on the fifteenth (15th) day of each month until your deductible is met. Once you meet your deductible, you will be charged your co-insurance amount only. If you have a co-pay plan, your card will be charged your monthly co-pay on the fifteenth (15th) of each month. Please add BCBS Insurance information below.
37
I understand that I am participating in an ongoing group therapy program at Family Strategies Counseling Center and that I will be charged monthly on the date outlined previously (1st for self pay and 15th for insurance) for my group fees.* This field is required.
Yes, I understand the payment terms for group participation.
38
I understand that my group fees are my responsibility and that I must keep a current card on file at all times.* This field is required.
Yes, I understand that I am required to keep a card on file for my group fees.
39
Aetna Member ID Number
40
Aetna Group Number
41
Is the registrant the primary insured (subscriber)?
YESNO
42
Primary Subscriber's Full Name
First Name
Last Name
43
Primary Subscriber's Date of Birth
Date
Year
Month
Day
44
What is your relationship with the Primary Subscriber?
Spouse
Parent/Child
Guardian
Other
45
BCBS Member ID Number
46
BCBS Group Number
47
Is the registrant the primary insured (subscriber)?
YESNO
48
Primary Subscriber's Full Name
First Name
Last Name
49
Primary Subscriber's Date of Birth
Date
Year
Month
Day
50
What is your relationship with the Primary Subscriber?
Spouse
Parent/Child
Guardian
Other
51
I understand that my insurance cannot be billed for any week I miss group and I will be charged a "no-show fee", of the regular cash pay rate, for the group meetings that I do not attend.
52
Please upload a picture of the front and back of your insurance cardaccepted file types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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53
PAYMENT OPTIONS* This field is required.If you are choosing to pay in full, please select the CORRECT group.
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Non-Refundable Deposit
$100.00Edit
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Daring Greatly™ for Men: PAY IN FULL
$850.00Edit
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Daring Greatly™ for Women: PAY IN FULL
$850.00Edit
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Rising Strong™ for Men: PAY IN FULL
$850.00Edit
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Rising Strong™ for Women: PAY IN FULL
$850.00Edit
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