• Chapter & Page Counseling — Group Counseling & Psychoeducation Group Registration

    Choose the group you’re interested in and share a little about the participant so our team can confirm your spot.
  • This form is for registering for a group at Chapter & Page Counseling. Our groups are either group counseling (a licensed clinician leads a small group working on shared goals) or psychoeducation groups (a structured, skills- and education-based group). Groups are not individual therapy. Each group listing below says which type it is.

  • Current group offerings

    These are our current group offerings. Some groups are actively accepting participants, while others are currently closed or will reopen at a later date. Please reach out to intakes@chapterandpagecounseling.com or check our website for more information, such as age limits/requirements, cost per session, and/or additional dates

    Annie's Groups — with Annie Custer, LCSW — $25 per session
    All other groups are $50 per session.

  • Participant Information

  • Participant's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is the participant under 18?*
  • Add Another Child

  • Help Us Make the Group a Good Fit

  • Has the participant ever had difficulty participating safely in a group setting?*

  • Current Services

  • Do any of the group participant(s) noted in this form currently receive services from Chapter & Page Counseling?*

  • Emergency Contact

  • Format: (000) 000-0000.
  • Authorized Pickup Person(s)*

  • Group expectations and Payment Contract

  • Chapter & Page Counseling wants groups to be welcoming, supportive, and safe. Participants are expected to respect other group members, staff, property, personal boundaries, and group confidentiality. Group facilitators may contact a parent/guardian or adult participant if additional information is needed to determine whether a particular group is an appropriate clinical or developmental fit. Registration does not guarantee placement until confirmed by Chapter & Page Counseling.

    Group cost: All groups are $50 per session, unless you are registering for Annie's Groups with Annie Custer, LCSW, which are $25 per session. No payment is required at this time. You will be billed after each session you attend. Group sessions are not covered by insurance. By registering, you confirm that you understand the cost and are responsible for payment for each session attended. For questions, email intakes@chapterandpagecounseling.com.

  • Privacy and group confidentiality

  • Group facilitators are responsible for protecting participant confidentiality according to applicable professional and legal requirements. Because groups include more than one participant, we ask all participants and families to respect the privacy of other group members. We cannot guarantee that another group participant will maintain confidentiality outside of group.

  • Group scheduling and participation requirements

  • Chapter & Page Counseling Services reserves the right to postpone, reschedule, suspend, or cancel any group based on enrollment, participant needs, group composition, or other circumstances affecting the group's ability to operate effectively.

    Groups require sufficient enrollment to support a safe, appropriate, and beneficial experience for all participants. Minimum enrollment requirements may vary depending on the nature and purpose of the group. Registration does not guarantee that a group will proceed as scheduled.

    Participants will be notified of any changes to their scheduled group.

  • Photo and media permission

  • May Chapter & Page Counseling photograph or record this participant for marketing or social media purposes?*
  • Choosing No will not affect eligibility or participation in the group.

  • Signature

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: