Name *

First Name

Last Name

Phone *

(###)

###

####

Will you use your insurance to cover the session fee? *

Yes, I have BCBS PPO

Yes, I have Aetna

Yes, I have Cigna

No, I will be paying out-of-pocket

Are you ok with art making if we provide supplies? *

Yes

No

Have you attended group therapy or individual counseling before?

Yes

No

Do you have a quiet, private place to attend sessions?

Yes

No

How did you hear about this group? *

Instagram

Facebook

Google

Word-of-Mouth

I heard Dr. Long discuss this group at an event

Other