Valor Group- Teens Group Therapy Registration
Valor Group- Teens meets every Wednesday from 4:00 - 5:30 pm at Family Strategies. All boys must have an intake assessment with a Valor Group therapist to join. Please call our office at (480) 668-8301 to schedule before registering.
Full Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
mm/dd/yyyy
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of School
*
Grade in School
*
Is client currently seeing a therapist at Family Strategies?
*
Yes
No
If yes, who?
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Parent Contact Information
Parent's Full Name
*
First Name
Last Name
You are the client's:
*
Mother
Father
Other
Parent's E-mail
*
Parent's Phone Number
*
-
Area Code
Phone Number
Parent's Full Name
First Name
Last Name
Parent's E-mail
example@example.com
Parent's Phone Number
-
Area Code
Phone Number
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Financial Information
How will you pay your group fees?
*
SELF-PAY - Your credit card will be securely placed on file with Family Strategies and will be charged on the first (1st) of each month. A current credit card MUST be kept on file unless other arrangements are made with, and approved by, the Family Strategies billing department.
THIRD-PARTY PAYER - If you have a previously arranged-for third-party to pay your son's fees, they will need to complete the "Third-party Payment Agreement" form and return to the front office BEFORE the first night of group. IT IS YOUR RESPONSIBILITY TO BE SURE YOUR SON'S ACCOUNT STAYS CURRENT. If your fees become 60-days past due, you will be contacted and your credit card on file will be charged.
BCBS INSURANCE - If your coverage is a deductible plan and you have not yet met your deductible, your card will be charged on the fifteenth (15th) day of each month until your deductible is met. Once you meet your deductible, you will be charged your co-insurance amount only. If you have a co-pay plan, your card will be charged your monthly co-pay on the fifteenth (15th) of each month. Please add BCBS Insurance information below.
AETNA INSURANCE-If your coverage is a deductible plan and you have not yet met your deductible, your card will be charged on the fifteenth (15th) day of each month until your deductible is met. Once you meet your deductible, you will be charged your co-insurance amount only. If you have a co-pay plan, your card will be charged your monthly co-pay on the fifteenth (15th) of each month. Please add Aetna Insurance information below.
Do you have BCBS Insurance?
*
Yes
No, I will be self-pay
No, I have Aetna
Do you have Aetna Insurance?
*
Yes
No, I will be self-pay
No, I have BCBS
Member ID
Please include all letters & numbers
Group Number
Primary Subscriber's Full Name
First Name
Last Name
Primary Subscriber's Date of Birth
/
Month
/
Day
Year
mm/dd/yyyy
Subscriber's Relationship to the Participant
Please Upload a Copy of Your BCBS Card
Browse Files
Please send images of the FRONT & BACK of your most current card
Cancel
of
We cannot bill insurance for a week your son does not attend group. Valor Group- Teens is a month-to-month commitment. Any week your son does not attend group, we will charge the card on file the regular self-pay rate of $65 charged at the time of your regular monthly group charge.
I understand that my insurance cannot be billed for any week my son misses group and I will be charged a "No-show Fee" of $65.
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Payment Information
I understand that I am registering my son for an ongoing group therapy program at Family Strategies Counseling Center and that I will be charged on the first (self pay) or fifteenth (BCBS) of each month for his group fees. I also understand that his group fees are my responsibility and that I must keep a current credit card on file at all times.
*
Yes, I understand the payment terms for group participation.
Payment
*
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( X )
Valor Group- Teens Registration Fee
$
100.00
One-time non-refundable registration fee does not apply to the monthly fees.
Total
$
0.00
Credit Card
Please verify that you are human
*
Submit Registration
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