Art for the Young at Heart Classes
Participant Email Address *
Todays Date: *
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Participant Name *
Preferred Name
Participant Date of Birth *
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Participant Address (Street, City, State)
Zip Code
Participant Phone Number *
It is okay for us to leave a voice mail or to text you at this number? *
Do you have a session preference *
How did you find us? *
Name of person completing form if different from the participant.
Relationship to Participant
Phone number of person completing form if different from the participant .
Does the participant have insurance? *
Insurance Carrier *
Member ID Number (with Alpha Prefix if applicable) for the Insurance Company listed above. Please make sure to enter the information accurately as we will not be able to verify the cost to you and what is covered if we do not have the accurate information. *
Group Number
Policy Holder's Name if Different From Participant
Policy Holder's Date of Birth if Different From Participant
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Policy Holder's Address if Different From Participant
Do you have mental/behavioral health benefits? *
If you have a deductible what is the amount of your deductible?
Has your deductible been met for this benefit year? *
What is your copay?
Secondary Insurance
Secondary Insurance Member ID #
What do you hope to achieve from participating in this class? *
Thank you for for submitting your request to participate in The Art for The Young at Heart class.
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