Interest Form for: Raising Kids With Big Baffling Behaviors: A Parent Course
Parent/Caregiver Details:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
I give permission for Benjamin McCormack, LCSW, RPT to email me about the parenting course:
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Phone Number
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I would would like to sign up for Raising Kids With Big, Baffling Behaviors: A Parent Course and would be available at the following time(s):
Sunday's anytime from 10:00-1:30
Saturday's anytime 7am-10am
Saturday's every other week, 10-1, 3 hours (Two modules each)
Individual parent coaching sessions focused around course materials (see rate below)
Anything needing clarification (optional)
Benjamin McCormack, LCSW, RPT, offers flexible payment plans to make the 12-week parent course accessible to all families. The total cost of the course is $480, which includes 12 weekly group sessions at $40 each. Each group meets for 1 hour and 30 minutes, totaling 18 hours of instruction. Please note: No payment or invoice is due at this time.
I am interested in seeing if my insurance will reimburse me for services and allow Benjamin McCormack to email me about more information
Pay in weekly installments: $40 non refundable deposit at registration, followed by eleven payments of $40 during the 12-week course
Pay in biweekly installments: $40 non refundable deposit at registration, followed by six payments of $73.33 during the 12-week course
Pay in two installments: $40 non refundable deposit at registration, followed by two payments of $220.00 during the 12-week course
Pay in one installment: $40 non refundable deposit at registration, followed by one payment of $440 during the 12-week course
Pay one installment for individual parent consults at $110 per session. No commitment to how many weeks
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