Mystic Dad's Group
When this group has 4 or more participants sharing desired interest our office will contact you to collect the one-time group fee over the phone with a credit/debit card or schedule a payment plan with our admin team.
Client Information
All information provided on this form is confidential
Client's Name
*
First Name
Last Name
Email
*
Phone Number
*
Preferred Method of Contact
*
Email
Phone
Is it okay to leave messages at this number?
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Yes
No
Is it okay to leave messages at this number?
*
Yes
No
I allow NFCC to contact me via email regarding group updates and billing
*
Please Select
Yes
No
I understand that there are risks associated with email communication and confidentiality
Which Day/Time works best for you?
*
Thursday Mornings 9-10am
Tuesday Evenings 5-6:30pm
Either day/time currently works for me
Are you currently receiving counseling or any other psychological or psychiatric services?
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No
Yes
If Yes, please explain
Acknowledgement of Receipt – Notice of Privacy Practices & Informed Consent for Treatment
*
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