GROUP REGISTRATION

Complete this form to reserve your spot for our new group, Balanced Beginnings. This group will be held at our office in Stamford. Upon completion, a clinician will be in touch with the next steps.

Participation Criteria: Female adolescent, ages 12-17
Details: Every Monday at 6pm, starting October 23^rd to November 27th
Pricing: All major insurances accepted in NY and CT; Out of Network or outside of NY & CT rate of $60 per session.

PARTICIPANT INFORMATION

Participant's First Name *

Participant's Last Name *

Participant's Date of Birth *

Participant Email Address

CAREGIVER INFORMATION

Full Name *

Phone Number *

Parent's Email Address *

Relationship to participant

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

By checking this box, I confirm that 1. I am committed to attending at least 5 of 6 sessions 2. I acknowledge that I may be charged a "drop out" fee if I choose to withdraw.

Confirm

Please provide any additional information:

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