Group Sign-Up Form
Group is $350 for the entire 10-weeks. We do not accept insurance for this group.
Preferred First Name *
Preferred Last Name *
Email *
Phone Number *
Date of Birth *
Must be at least 18 year of age to enroll in group.
Legal Name (if different from preferred name)
Preferred Pronouns
How did you hear about us?
Doctor/Professional
Facebook
Friend/Family
Google Search
Instagram
Monarch
My Insurance Company
Psychology Today
Other
Please Specify if 'Other' was Chosen
By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. You also agree to have someone from our team contact you by phone and/or email. *
Submit