R.I.S.E Book Club Registration Form

R.I.S.E Book Club Registration Form

Thank you for your interest in being part of our sisterhood. Whether you’re a returning Sistah or joining us for the first time, we’re excited to journey with you. Please take a few moments to complete the form below so we can keep your information up to date. Answer each question as best you can. We can’t wait to grow, laugh, and rise together this season!
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Thank you for your interest! At this time, Book Club membership requires participation in our in‑person gatherings located in Pittsburgh, PA.
We’ll keep your information on file in case we launch a virtual option in the future!
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*
Self-PayInsurance (we can not accept Medicare)FSA/HSA CardFinancial Hardship
Payment Information:

You will receive an invoice from QuickBooks monthly. You can pay through, Debit, Credit, Paypal. This invoice will be automatically generated and emailed each month as part of a recurring billing schedule. Any invoices not paid, by due date, invoices will be texted.

if you are interested in setting your account up for automatic payment You can choose to set up automatic payments directly through the invoice. To do this, when you recevie the Quickbooks invoice, open the invoice and click “Set up automatic payments” at the top, and follow the prompts to securely save your preferred payment method for future invoices.
Insurance Process

You will receive an email from Healthie on behalf of Camille Clarke LLC / THAW to complete the necessary documents for insurance billing.

Billing is managed through DLP Mental Health Services, which will submit claims under the diagnosis code F41.1 (Generalized Anxiety Disorder) for four group sessions per month to cover your R.I.S.E. membership.

Please note that insurance coverage varies by plan. Within approximately 30 days, we will confirm whether your insurance has been accepted. If your plan is not accepted, we’ll notify you so that you can update your payment preference or switch to the self-pay option.

If you prefer not to use insurance, you may change your payment method at any time.
YesNoUnsure
Vision BookVision Board
Do you have any dietary restrictions? If so, please list below. *
Printed Physical BookAudible (Amazon Audio)Kindle (Amazon Digital)Apple Audio BooksApple Digital Book
Email address for your audio or digital book.
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By signing below, I acknowledge that I have read and agree to the R.I.S.E. Book Club Policies, Code of Conduct, and Confidentiality Agreement.*
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