Interest Form: Care for the Caregivers Support Group
Please provide us with some information about yourself and the person you are caring for.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
Insurance Carrier
Please Select
Aetna
Anthem/Blue Cross Blue Shield
Fidelis/Ambetter
Healthfirst
Meritain
MetroPlus
Out-of-Network Benefits
Out of Pocket ($125/session)
Oscar
Oxford
UMR by UnitedHealthcare
UnitedHealthcare Commercial Plan
Member ID
What is your relationship to the person for whom you’re providing care?
How old is this person and what mental health issues does the person have?
How are you affected by these issues and your caregiving role?
What do you hope to gain from attending this group?
Are you currently in individual therapy?
Please Select
Yes
No
If you are in individual therapy with City Therapy, please provide your therapist’s name here. If another practice, please list the name and contact information for the practice:
Have you had thoughts of suicide in the past month?
Please Select
Yes
No
Are you currently experiencing food insecurity or unstable housing?
Please Select
Yes
No
Are you currently experiencing physical or emotional abuse?
Please Select
Yes
No
I'm Not Sure
Are you currently experiencing any legal problems?
Please Select
Yes
No
Do you have any questions about the group?
The Care for the Caregivers Group will be held on Friday mornings starting on January 31, 2025. We ask that members commit to regular attendance. Please sign below to attest that you agree to this commitment and have provided truthful and accurate information above.
Please Sign Below
Signature
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