Brave Hope Counseling Group Interest Form

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We are excited to have you join one of our amazing Group Therapy options

Which group do you wish to participate in *

Living Beyond Your Pain with Lacy Findley

Transforming Trauma 1.0 with Jenna Estep

Are you a current or previous client of Brave Hope Counseling? *

Yes

Legal First & Last Name: *

Preferred Name (if different)

Email address *

Date of Birth *

YYYY

Phone Number *

Pronouns *

Group therapy requires an assessment appointment prior to beginning group. Are you okay with completing the assessment process? *

Yes

Other:

Required

Payment & Insurance Information *

Aetna

CareOregon

Trillium

Self-Pay *A discount is offered for advance payment of all sessions*

Insurance Member ID

(N/A for Self-Pay)

Attendance is essential for success.

Are you able to commit to the group for multiple weeks?

Yes

As a thank you for spreading the word, we’re entering all referrals into a special giveaway!

Please let us know how you heard about our groups or who referred you. If you saw our flyer, where did you see it?

Your feedback helps us improve, and we appreciate your support!

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