PFHL Group Registration Request Form
Groups are scheduled on a first-come-first-served basis. Groups are generally covered by most insurance companies (please call yours to verify coverage). The fee for group is $50 (this is the amount we bill to your insurance company), but the amount allowed by most insurance companies is usually less. The amount we charge for patients who don't have insurance and wish to pay out of pocket is $40 per group session. Some of our groups/workshops in 2020 will be offered free of charge, and those will be marked as such in the group/workshop description below.
Which group(s) would you like to attend?
ADHD Skills Group for Adults - Wednesdays in November 2019 from 6 to 7 PM in Lewis Center (8351 N High St Ste 155)
DBT Skills Group for Adults and Adolescents (16+) - Mondays (ongoing) from 5:30 to 6:30 PM in Gahanna (540 Officenter Pl Ste 160)
ADHD Skills Group for Adults - Mondays in December 2019 from 5:30 to 6:30 PM at Fishinger (3535 Fishinger Blvd Ste 110, Hilliard)
Nutrition Workshop - Another New Year's Resolution! Setting Goals & Getting Motivated to Lose Weight in 2020 - Tuesday, 1/7/20, from 6 to 7 PM at Trueman (3933 Trueman Blvd, Hilliard) - FREE FOR ESTABLISHED PATIENTS
Nutrition Workshop - What Diet is the Best? Fad Diets, Nutrition Basics & the Right Diet for You - Wednesday, 1/15/20, from 6 to 7 PM at Trueman (3933 Trueman Blvd, Hilliard) - FREE FOR ESTABLISHED PATIENTS
Nutrition Workshop - Losing Weight Isn’t Easy! How Exercise, Counseling and Medications Can Help - Tuesday, 1/21/20, from 6 to 7 PM at Trueman (3933 Trueman Blvd, Hilliard) - FREE FOR ESTABLISHED PATIENTS
Nutrition Workshop - Planning Meals Takes So Much Time! Easy Strategies for Grocery Shopping, Meal Prepping & Eating Out Less in 2020 - Wednesday, 1/29/20, from 6 to 7 PM at Trueman (3933 Trueman Blvd, Hilliard) - FREE FOR ESTABLISHED PATIENTS
Patient Date of Birth:
I understand that once my appointment is scheduled, I will be expected to attend unless I provide at least a 24-hour advanced notice otherwise.
I understand that if I do not provide at least 24-hours advanced notice, or if I fail to show up for a group, it will result in a $30 no show/late cancellation fee.
By typing your name below, you certify that you have read and agree to all the policies outlined above, and agree to be held by the consequences of these acknowledgments. (Please type the full legal name of the person completing this form. By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.)
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This form was created inside of Providers for Healthy Living, LLC.