Mind & Body Restoration Program Eligibility Form

Mind & Body Restoration Program Eligibility Form

Thank you for your interest in the Mind & Body Restoration Program. Please complete this brief form so our team can learn more about your needs and determine the appropriate next steps. Completion of this form does not guarantee enrollment or insurance coverage.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you currently enrolled in Medicaid?
Which insurance do you have?
What are your primary health concerns or goals for joining this program?
Do you have any current or past mental health diagnoses?
Are you trying to lose weight?
Do you have any physical health conditions we should be aware of?
If yes, please specify your physical health conditions.
Are you currently taking any prescription medication?
What are you hoping to gain from the Mind & Body Restoration Program?

Other
Are you able to participate in programming 3-4 days per week for approximately 2.5 hours per day?
Which session would work best for you?
How did you hear about the Mind & Body Restoration Program?

Other
Should be Empty: