Affirmations Grief and Loss Counseling Group Interest Form
This Form is for those who are interested in the Grief and Loss Therapy Group at Affirmations. This group is not a support or discussion group, rather a therapy group led by clinicians and use structured treatment goals, interventions and techniques. This group will run weekly on Tuesdays beginning mid-February. Please complete the following fields and we will be in touch! **Please note that this is an interest form, and does not guarantee acceptance into the group**
Name
*
First Name
Last Name
Pronouns
*
She/Her
He/Him
They/Them
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Is it okay to leave a detailed message stating that someone from Affirmations is contacting you?
*
Yes
No
Email
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Will you be using insurance? If yes, please provide the name(s) of your insurance provider(s) and specify if it is commercial, Medicaid, Medicare, or a combination. If you have multiple health insurance plans, we will need details for each one. Additionally, please send pictures of all insurance cards before we proceed.
*
Insurance member number or ID number
*
Is there anything else that you think we should know or that we should keep in mind?
Submit
Should be Empty: