BoB Registration Form

Band of Brothers Registration

Client Information
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
mm/dd/yyyy Date Picker Icon

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Name of School *
Grade in School *
Is client currently seeing a therapist at Family Strategies? *

Yes No
If yes, who?

Parent Contact Information
Parent's Full Name *

First Name Last Name
You are the client's: *

Mother Father
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

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 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 first 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 co-pay on the first of each month. Please add BCBS Insurance information on the next page.
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 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.
Date *

Month Day Year
Date Date Picker Icon
Do you have BCBS Insurance? *

Yes No, I will be self-pay
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 Date Picker Icon
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. Band of Brothers 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 $50.

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 $50.
Should be Empty:

Band of Brothers Registration

Parent Contact Information

Financial Information