Brave Hope Counseling Group Therapy Interest Form
This form is to solicit interest in attending group therapy at Brave Hope Counseling. 
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Are you a current or previous client of Brave Hope Counseling?  *
Legal First & Last Name: *
Preferred Name (if different)
Email address *
Date of Birth *
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Phone Number *
Pronouns *
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Group therapy requires an assessment appointment prior to beginning group. Are you okay with completing the assessment process?  *
Required
Payment & Insurance Information *
Insurance Member ID
(N/A for Self-Pay)
 *
Attendance is essential for success.
Are you able to commit to the full 8 week group process?
 *

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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