Cognitive Behavior Therapy (CBT) Center Group Treatment Interest Form 
Thank you for your interest in the CBT Center Group Therapy Program!

Please take a few minutes to fill out this quick form. It is important for us to make sure we understand what you need so that we can assess whether us and our services are a good fit for what you need right now. We practice only the most evidence-based treatments and want to make sure we have the expertise to help you.

This form should only be completed by people 18 years and older. If you are younger than 18, please have a parent or legal guardian complete it for you.
Sign in to Google to save your progress. Learn more
Email *
How did you hear about our groups? *
If referred to us, please indicate who sent you our way.
What is your first name? *
What is your last name? *
What is your date of birth?

Please note: We treat middle school-aged through older adult - ages ~12+
What is the best way to contact you? 

Note: text messages and email make it easier for us to get back to you more quickly between meetings, etc.
What is your phone number? *
What is your preferred email address? *
Why are you hoping to get out of group treatment? (just a few bullet points) *
Are you currently engaged in individual treatment? *
Have you ever done group therapy before? *
*If you currently are having suicidal thoughts in addition to having plans or the means to do so, please go to the nearest emergency room, call 911, call the National Suicide Prevention Lifeline (1-800-273-8255), or text “START” to the Crisis Text Line (741741). If you are outside of the country, please call the local emergency line immediately.*
We are considered an out-of-network provider which means that your insurance may or may not cover the cost of our services. However, we work hard to make our services accessible. If you have a Preferred Provider Organization (PPO) plan, they typically reimburse around 70-80% for out-of-network providers.
Please confirm that you understand the following:

You will be required to pay for your session in full at the time of service. We will provide you with a superbill at the end of each month that you can submit to your insurance company for reimbursement. We accept cash, check, or credit card; however, we require a credit card on file.

For therapy groups, you will be required to participate in and pay for all sessions - much like a college course.

*To learn more about our current fees and insurance, visit the FAQs ( page on our website.*

Please confirm that you are willing to pay out of pocket for our services by initialing below indicating that you understand that the CBT Center is an out-of-network provider and you are willing to pay out of pocket for their services.
What state(s) will you be located in during therapy?
Is there a specific CBT Center group you would like to join? 

Do you have any special requests regarding your treatment? What else is important for us to know? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Report Abuse