Aspen Ridge Counseling Group Enrollment Form

Aspen Ridge Counseling Group Enrollment Form
Participant's Legal Name*

First NameLast Name
Parent/Guardian Name (if applicable)

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Is the Participant a current client at Aspen Ridge?*

YesNo
Participant's Insurance Provider (Please enter self-pay if the participant does not have insurance)*
Which group are you interested in?*
By submitting this form, I acknowledge that additional paperwork or information may be required to complete my enrollment. I understand that a representative may contact me using the information provided to gather any necessary details. I also acknowledge that submitting this form does not guarantee a spot in the group, as availability may be limited. My participation will be confirmed once all necessary steps are completed.
I acknowledge the statement above:*

YesNo
Signature*

Clear
Should be Empty: