DBT Group Registration Form
When: Wednesdays from 6 - 7:30 PM & Saturdays from 11:30 AM - 1 PM.

Duration: Twice weekly for 6 weeks, starting February 10th.
*Attending both weekly sessions is strongly recommended.*

Where: Held online.

The cost of this group will vary based on individual insurance coverage or cash pay rate. The office can review this with you.
First Name *
Last Name *
Email *
Phone Number *
Are you a new patient? *
Please select your insurance from the list provided. If you do not see your provider or do not have insurance, please select "Other". *
If you selected "Other" above, please enter your insurance provider below. If you do not have insurance, please enter N/A.
Our staff will contact you to discuss registration, billing and the intake process (if necessary). What is your preferred method of communication? *
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This form was created inside of Women's Health Innovations of Arizona.