EESG Winter/Spring 2025

Emotional Eating Support Group: February 20 - April 10th, 2025

Fill out this form to let us know you are interested so we can reach out and determine whether this class is right for you.
Enrollment in full course is required.

Instructor: Sabine Haake, MBA, RD

Step 1: Complete this form by filling in your contact information.

Step 2: Complete Intake Interview (Sabine will contact you)

Step 3: Confirm payment option (our office will contact you)

Payment options include select insurances and out-of-pocket:

· HMO Brown & Toland – This course is FREE for HMO Brown & Toland members

· Blue Shield - Fee determined based on your specific plan; Copay may apply

· Out-of-Pocket Payment: $60/class, totaling $480.00 (PayPal, Credit Card, or Check)
First Name*
Last Name*
Email*

Confirmation Emailexample@example.com
Contact Phone Number*

Area CodePhone Number
Birthdate*

MonthDayYear
Date
Which payment option do you intend on using?*

I am an HMO Brown & Toland member.I have Blue Shield.I will be paying out of pocket.I am not sure.
If you have Blue Shield, enter your subscriber ID #.
Required to determine your coverage and fees for this group class.
Tell us how you heard of this class?*
Social media (specify), healthcare provider (name), friend, flyer, etc.
Should be Empty:

Emotional Eating Support Group: February 20 - April 10th, 2025