GROUP THERAPY

Full Name*

First NameLast Name

Date of Birth*

Date

Contact Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email Address*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Name [if you do not have insurance, please type none]*

Insurance Member ID [if you do not have one, please type none]*

My preference of pay is*

Direct PayI intend to use insurance if insurance billing is an option

Which group are you interested in?*

I understand that some groups may not be eligible for insurance billing and will require out-of-pocket payment. I acknowledge that it is my responsibility to confirm whether the group is covered by insurance or will be an out-of-pocket expense prior to the start of the group.*

I agree

I understand that each group has a minimum and maximum participant requirement. If the minimum number of participants is not met, the group will be rescheduled to a later date or canceled, and I will be notified accordingly.*

I agree

I understand that payment can only be made by card or in cash and that payment must be received before the start of each group session.*

I agree

I understand that I or my child may be required to complete a screening process to determine whether the group is an appropriate fit. I understand that submitting this form or signing up for a group does not guarantee placement or a reserved spot in any group.*

I agree

If you have any additional comments or questions, please leave them below!