GROUP REGISTRATION

Complete this form to reserve your spot for the Fall 2023 Empty Nesters Group. Upon completion, a clinician will be in touch with the next steps.

Participation Criteria: Mothers with an empty nest (i.e. all kids gone to college, moved out, etc.).

Participation Method: This group requires virtual participation. A link will be sent out to participants after registration is complete.

Details: Every Wednesday at 6pm, starting September 20th to November 8th.

Pricing: All major insurance accepted in CT and FL; Out of Network or Outside of CT & FL rate of $60 per session (credit card required to complete registration).

PARTICIPANT INFORMATION

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

Relationship Status

One word that describes how you feel about being an empty nester

How many children and how old are they?

INSURANCE INFORMATION

Insurance Carrier

Subscriber ID

Provider Services # (Back of Card)

Upload a photo of your Insurance card (Front and Back)

Maximum file size: 10MB

How did you hear about the group?

Please provide any additional information:

By checking this box, I confirm that 1. I am committed to attending at least 6 of 8 sessions 2. I acknowledge that I may be charged a "drop out" fee if I choose to withdraw.

Accept Terms

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