Tribe Group Therapy Registration

Tribe Group Therapy Registration

Tribe meets every Monday from 4:00 - 5:30 pm at Family Strategies. Contact us at (480) 668-8301 with any questions. We look forward to working with you!
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
mm/dd/yyyy
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Registration Information
I have completed an intake session with a Family Strategies therapist:*

YesNo
I was recommended for the Tribe program by:
If different than above, who is your current therapist?
SAST Score (Select one):
Please tell us about your situation (responses are kept confidential):*
Do you have any questions or concerns:
Would you like to be contacted before the start of group to discuss any questions or concerns?*

YesNo

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 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 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.
Do you have BCBS Insurance?*

YesNo
Member ID
Group Number
Is the registrant the primary insured (subscriber)?

YesNo
Primary Subscriber's Full Name

First NameLast Name
Primary Subscriber's Date of Birth

MonthDayYear
mm/dd/yyyy
Subscriber's Relationship to the Participant
Please upload a copy of your BCBS insurance card

Browse Files
Please send images of the FRONT and BACK of your most current card. Cancelof
We cannot bill insurance for a week you do not attend group. Tribe is a month-to-month commitment. For any week you do not attend group, we will charge the card on file the regular self-pay rate of $65 at the time of your regular monthly charge.

I understand that my insurance cannot be billed for any week I miss group and I will be charged a "no-show fee" of $65.

Payment Information
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 (self-pay) or fifteenth (BCBS) 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.

Payment*

Tribe Registration Fee$100.00

This is a one-time non-refundable registration fee that does not apply toward monthly fees.

Total $0.00

Credit Card

**ONCE YOU COMPLETE YOUR REGISTRATION YOU WILL RECEIVE A CONFIRMATION EMAIL. IF YOU DO NOT, PLEASE CALL OUR OFFICE TO VERIFY YOUR REGISTRATION.
Please verify that you are human*
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Tribe Group Therapy Registration

Registration Information

Financial Information

Payment Information

Credit Card