GROUP THERAPY
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / 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 Pay
I intend to use insurance if insurance billing is an option
Which group are you interested in?
*
Please Select
Men's Support Group
Women's Infant Loss Support Group
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, and I will be notified accordingly.
*
I agree
I understand that if I have to make a direct payment, it can only be made by card payment or cash, and that payment must be received before the start of each group session.
*
I agree
If you have any additional comments or questions, please leave them below!
Submit
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