Restore Group Registration
Restore is an education and support group for women who are navigating infertility and pregnancy loss. This compassionate and respectful space is designed to provide understanding, connection, and tools to help in your very personal healing journey.
Full Name
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First Name
Last Name
Birthday
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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E-mail
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example@example.com
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Questionnaire
Your willingness to answer the questions below will help us best assess your readiness for a group experience such as this. thank you so much for your cooperation in answering these questions.
How would you describe your experience with pregnancy loss or infertility?
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I've struggled with inferitlity
I've experienced pregnancy loss ( miscarriage, stillbirth, ectopic pregnancy, molar pregnancy)
Both
Other
How long have you been dealing with this?
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Less than 6 months
6 months to 1 year
1-3 years
3-5 years
More than 5 years
What is your current emotional state related to your experience?
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I feel overwhelmed and unable to cope
I am struggling but managing day-to-day
I am feeling more at peace, but the pain is still there
I am mostly at peace with my experience
Other
On a scale of 1-10, how would you rate your current emotional well-being? (1= extremely distressed, 10= feeling emotionally balanced)
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1
2
3
4
5
6
7
8
9
10
Have you participated in any previous support groups or therapy?
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Yes, I have been in a support group
Yes, I have been in individual counseling
Yes, both support group and individual counseling
No, I haven't participated in either
Are you comfortable discussing your personal experiences in a group setting?
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Yes, I feel ready
I am unsure, but I am willing to try
No, I prefer one-on-one support
How comfortable do you feel discussing your emotions in a group setting?
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Very comfortable
Somewhat comfortable
Unsure
Somewhat uncomfortable
Very uncomfortable
Are you currently seeing a therapist at Family Strategies?
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Yes
No
If you are seeing a therapist at Family Strategies, who is it?
What form of support are you currently receiving?
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Individual therapy
Couple's counseling
Medical support (e.g., fertility treatments)
None
Other
What are the main emotional challenges you are currently facing? (select all that apply)
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Grief
Anger
Guilt
Anxiety
Depression
Isolation
Other
What coping strategies have you found helpful so far? (Select all that apply)
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Talking with friends or family
Meditation or mindfulness
Journaling or creative outlets
Exercise or physical activities
Therapy or counseling
Other
What topics would you like the group to focus on? (select all that apply)
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Coping with grief after loss
Navigating infertility treatments
Managing relationship challenges during loss or infertility
Building resilience and emotional regulation
Dealing with anxiety or depression
Creating a safe space for emotional expression
Other
Can you commit to regular attendance for the group sessions?
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Yes, I can attend regularly
Yes, but I may occasionally have to miss a session
No, my schedule is inconsistent
Other
How strong is your support system outside of the group?
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Very strong (I have family, friends, and a partner who are supportive)
Somewhat strong (I have some support, but it is limited)
Not strong (I feel isolated and alone)
Other
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Financial Information
There is a $100 deposit due at the time of registration that will be applied to the overall workshop fee. If you have insurance, please submit your information below.
How will you pay your group fees?
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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 Aetna Insurance information below.
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.
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Yes, I understand the payment terms for group participation.
I understand that my group fees are my responsibility and that I must keep a current card on file at all times.
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Yes, I understand that I am required to keep a card on file for my group fees.
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BCBS Insurance Details
You indicated that you have BCBS insurance. Please have your insurance card and information available to answer the questions in this section
BCBS Member ID Number
BCBS Group Number
Are you the primary insured (subscriber)?
Yes
No
Primary Subscribers Full Name
First Name
Last Name
Primary Subscribers Date of Birth
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Month
-
Day
Year
Date
What is your relationship with the Primary Subscriber?
Spouse
Parent/Child
Guardian
Other
We CANNOT bill insurance for a week that you do not attend group. The Daring Way is a FULL COMMITMENT to attend all weeks of the program. Any week you do not attend, we will charge the card on file the regular self-pay rate on the first of the following month
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.
Please upload a picture of the front and back of your insurance card
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Aetna Insurance Details
You indicated that you have Aetna insurance. Please have your insurance card and information available to answer the questions in this section.
Aetna Member ID Number
Aetna Group Number
Are you the primary insured (subscriber)?
Yes
No
Primary Subscribers Full Name
First Name
Last Name
Primary Subscribers Date of Birth
-
Month
-
Day
Year
Date
What is your relationship with the Primary Subscriber?
Spouse
Parent/ Child
Guardian
Other
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Payment Information
A non-refundable deposit of $100 is required at the time of registration to reserve your spot in the group.
My Products
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Non-refundable fee
$
100.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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