Tribe Registration

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 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 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 below. I would like more information on the Financial Assistance offered by Family Strategies.

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

Member ID

Group Number

Is the registrant the primary insured (subscriber)?

Yes No

Primary Subscriber's Full Name

First Name Last Name

Primary Subscriber's Date of Birth

mm/dd/yyyy

We cannot bill insurance for a week you do not attend group. Tribe is a month-to-month commitment. Any week you do 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 I miss group and I will be charged a "No-show Fee" of $50.

**ONCE YOU COMPLETE YOUR REGISTRATION YOU SHOULD RECEIVE A CONFIRMATION EMAIL. IF YOU DO NOT, PLEASE CALL OUR OFFICE TO VERIFY YOUR REGISTRATION.

Enter the message as it's shown *

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

Tribe - PHASE ONE REGISTRATION