ANCHOR Interest Form

ANCHOR Interest Form
EVERY MONDAY FROM 5:30-7:00pm

ANCHOR is an ongoing process group providing members with mutual support, self-awareness, interpersonal skills, and attachment healing. Adults 18+ are welcome.

This group is billable to insurance. We are in-network with Aetna, BCBS, Cigna, United, and limited Medicaid plans. If you choose not to use insurance, the fee is $40 per group session.
Name:*

First NameLast Name
Age:*
Preferred Pronouns
Are you a former or current KCC client?*

YesNo
Client Date of Birth*

MonthDayYear
Date
Client Email*
example@example.com
Client Phone Number*
Please enter a valid phone number.
Can you consistently attend meetings on Mondays from 5:30-7:00pm?

YesNo

In order to join ANCHOR, you must attend an orientation session with our group leader. Please select all times you would be available to schedule this meeting:*

	10 AM	11 AM	12 PM	2 PM	3 PM	4 PM	5 PM
Monday
Tuesday
Wednesday
Thursday
Friday

Is there anyone you would not be comfortable with attending ANCHOR? Please provide their name(s).
Is there anything you want our group leaders to know before the first group session?
Contact Genevieve Stafford, our Group Coordinator, with any questions.

Genevieve@kernersvillecounseling.com

336-283-3830 ext. 26
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