Renewed Hope Counseling - Group Registration

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Please complete this form to register for your preferred group session. All information provided is kept strictly confidential.

Email *

Record my email address with my response

Name of Participant *

Parent/Guardian *

Email Address *

Phone Number *

Select the group you wish to join *

Coping Skills Thursday 9-10a,m

Coping Skills Saturday 11-12

Middle School Girls Group

If you plan to utilize insurance, please choose carrier *

Anthem

Aetna

United

Husky

Other (out of network)

Required

Any additional Questions?

Agreement to Policies

I understand that group therapy requires consistent attendance.

I agree to respect the confidentiality of all other group members.

I acknowledge that this registration is subject to a brief intake screening.

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