Please include:

✔️ Name (first, last, and preferred if different)

✔️Pronouns

✔️Birth Date

✔️Phone Number

Thank you!

This is an in-person group, so we want to make sure you'll be able to attend 💛

We will use this email to contact you. Please make sure the spelling is correct 💛

If you do not have insurance, please choose "No".

Please note: We offer direct billing with select insurance providers (you can find the list on the group’s webpage). If your provider isn’t on the list, you may still be able to submit receipts manually for reimbursement through your insurance. Our office coordinator will be happy to assist you once we receive your form.

If you do not have insurance, please indicate that in the box below and "Submit".