Group Therapy Sign Up

Group Therapy Sign Up
Please fill out this form to sign up for a group therapy program. We will follow up with you soon.

This form is not for emergencies. If you need immediate assistance, please call 911.
Which group therapy program are you registering for?

The Social Circle for ages 5-8 starting June 15thThe Social Circle for ages 9-12 starting June 15thThe Social Circle for ages 13-18 starting June 15thExecutive Functioning Skills for ages 5-8 starting June 16thExecutive Functioning Skills for ages 9-12 starting June 17thExecutive Functioning Skills for ages 13-18 starting June 16thAnxiety Skills Group for ages 5-8 starting June 17thDungeons, Dragons, & DiscoveryType option 2Type option 4
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Age*
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type a question*

Private PayBlue Cross Blue Shield of MichiganBlue Care Network
BCBS/BCN Member ID
BCBS/BCN Group #
How did you hear about Pleasant Psychology?*
e.g., Dr. Smith, Google, Facebook
Would you like to receive our newsletter with parenting tips and resources? (You can unsubscribe anytime)

YesNo
Email and Text Messaging Consent*

I understand
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Group Therapy Sign Up

Please fill out this form to sign up for a group therapy program. We will follow up with you soon.