Rising Strong Registration

RISING STRONG™: A 2-Day Intensive for Women

November 1st & 2nd, 9am - 5 pm
Daring Way™ Groups Registration

Thank you for submitting the form below. Please complete the * sections to provide the confidential information needed to complete your registration. The rest of the questionnaire is optional, however, your willingness to complete it will help us know you better as you embark on this journey. Your participation in the workshop/group will be confirmed upon receipt of your payment along with the submission of The Daring Way™ Questionnaire and The Daring Way™ Consent Form found under the "MORE" tab.
Name *

First Name Last Name
Date of Birth *

Month Day Year
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Email *
example@example.com
Phone Number *

Area Code Phone Number

Address *

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

Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

Area Code Phone Number
How did you hear about this workshop/group? *
Would you like to be included on our email list for future events? *

Yes No

The Daring Way™ Questionnaire

Your facilitator for this workshop has completed an extensive training process with The Daring Way™ to teach this curriculum. Your willingness to answer the questions below will help us best assess your readiness for a group experience such as this. Thank you so much for your cooperation in answering these questions.
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)

Yes No
If yes, when? Please briefly list the reasons and outcomes.
Do you have a therapist you could work with if something came up in this workshoprequiring individual/couple attention?

Yes No
If not, would you like referrals to therapists?

Yes No
Are you currently taking any medication for mental health issues?

Yes No
If yes, please explain:
Are you in recovery from substance or alcohol abuse? If so, how long have you beensober? Please provide a brief description of the treatment and support you receive for maintaining sobriety?
Do you have a history of eating disorders or disordered eating? If so, please provideinformation on the support and treatment you are/have received.
Have you experienced distressing life events (trauma, loss, etc.) that have significantly impacted your functioning and quality of life? If so, please provide information about how you have addressed these issues.
What sparked your interest in our workshops?
What would you like to accomplish as a result of attending our workshop?
What previous experience have you had, if any, with group therapy or a support group?
Please list dates and the name of the group.
How were they helpful?
What difficulties did you have, if any?
What concerns, if any, do you have about participating in a group experience?
How would you respond as a group member if someone in the group dominated thediscussion?
How would your respond as a group member if someone never participated in the group discussion?
What else would you like us to know about you?
Thank you so much for providing this information! We will review the information you provided and follow up with you to confirm your registration.

For questions or more information you may contact us at: ahatch@familystrategies.org

Group Payment Information

There is a $100 deposit due at the time of registration that will be applied to the overall workshop fee of $600 per person. If you have BCBS, please submit your information below.
How will you pay for your group fees? *

SELF PAY - Your credit card will be securely places on file with Family Strategies and will be charges 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 or if you pay in full at time of registration. THIRD-PARTY PAYER - If you have previously arranged for a third-party to pay for your fees, they will need to complete the "third-party Payment Agreement" form and return to the front office BEFORE the first night of group. We also require that you keep a credit card on file. IT IS YOUR RESPONSIBILITY TO BE SURE YOUR 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 has been met. Once you meet deductible, you will be charged your copay/co-insurance amounts on the first of each month FOR THE MONTH. Please fill out the BCBS information below. BCBS CAN NOT BE BILLED FOR MISSED SESSIONS, YOUR CARD WILL BE CHARGED THE SELF-PAY RATE FOR THOSE DATES.
I understand that I am participating in an ongoing group therapy program at Family Strategies Counseling Center and that I will be charged on the first of each month for my group fees. I also understand that my 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.
Do you have BCBS insurance? *

Yes No
BCBS Member ID
Member ID's that begin with 'R' or 3 letters DO NOT need a group number
Group Number
Group number MUST begin with 3 letters (check the back of your card)
Is the registrant the primary insured (subscriber)?

Yes No
Primary Subscriber's Full Name

First Name Last Name
Primary Subscriber's Date of Birth

Month Day Year
Use format: mm-dd-yyyy Date Picker Icon
We cannot bill insurance for a week that you do not attend group. The Daring Way is a full commitment to attend all weeks of the program. Any week you do not attend, we will charge the card on file the regular self-pay rate of $75 on the first of the following month.

I understand that my insurance cannot be billed for any week I miss group and I will be charged a "no-show fee" of $75.

Registration Payment

Payment Options *

Rising Strong™ 2-Day Intensive: Deposit Only $ 100.00

Rising Strong™ 2-Day Intensive: Pay in Full $ 600.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please print and sign the following forms and bring with you on your first night of group.
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RISING STRONG™: A 2-Day Intensive for Women

Daring Way™ Groups Registration

The Daring Way™ Questionnaire

Group Payment Information

Registration Payment