BLUE UMBRELLA PSYCHIATRY SHE THRIVES WOMEN WORKSHOP PARTICIPATION AGREEMENT & WAIVER LIABILITY
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
I understand that this workshop is
educational and supportive in nature
, and that
no specific outcomes or results are guaranteed
..
*
I understand.
I understand that this is a
self-pay workshop
and is
not billable through insurance
under any circumstance.
*
I understand
I understand that the workshop will be
facilitated by Jesimar El Yamel, LMHC
, a licensed mental health counselor.
*
I understand
I understand that while this group may be therapeutic in nature, it is
not a substitute for individual therapy, crisis care, or emergency services
.
*
I understand
I understand that I am expected to participate respectfully and maintain the
confidentiality of all group members
, although full confidentiality cannot be guaranteed due to the group setting.
*
I understand
I give my
full consent to participate
in the SHE THRIVES Women’s Workshop and understand the nature and expectations of the program.
*
I understand
I understand that the total cost of the
SHE THRIVES Women’s Workshop
is
$320 for the full 8-week session
,
regardless of my attendance
. and I understand that I have two payment options:
*
I understand
Preffered Payment schedule
*
Please Select
pay in full $320 on 10/1/2024 and understand there will be no refunds if I don't attend
pay $40 every date of workshop regardless of my attendance (10/7, 10/21, 11/4, 11/18, 12/2, 12/16,1/6, 1/20)
Credit card number to be used for workshop payment, in accordance with the payment schedule you selected above.
*
Expiration Date
*
CVV (Security Code)
*
I authorize
Blue Umbrella Psychiatry
to charge my credit card on file or the one uploaded according to the
payment schedule I have selected above
for the SHE THRIVES Women’s Workshop.
*
I understand.
Date
*
-
Year
-
Month
Day
Date
Signature
*
Should be Empty: