Grief Group Registration Form

Group Sign-Up Form

Preferred First Name *
Preferred Last Name *

Email *

Phone Number *

Date of Birth *

Must be at least 18 year of age to enroll in group.

Primary Payment *

Please specify payment method if you chose "other"

If you are using insurance for group please provide the following information so that we can bill on your behalf. We accept Aetna, Cigna, Tricare and TriWest/VA. Please note: You will be subject to your co-pay or any cost-shares from your insurance each week.

Primary Insurance Policy/Member ID Number

For Tricare folks this is your 11-digit Benefits ID number that starts with "0" and is on the back of your military ID

Active Duty Military?

YesNo

Legal Name (if different from preferred name)

Preferred Pronouns

How did you hear about us?

Doctor/ProfessionalFacebookFriend/FamilyGoogle SearchInstagramMonarchMy Insurance CompanyPsychology TodayOther

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. *