Breaking Free - Group Registration
The Breaking Free therapeutic group helps the adolescents and teens develop an understanding about addiction and its accompanying behaviors while being provided the opportunity to develop skills for recovery in their lives in a supportive group approach.

Meets bi weekly

Cost is $50 per group - session


Location:

Bevill and Associates
2524 Valleydale Rd
Suite 100
Birmingham, AL 35244

Directions:
To participate in this group you must currently be in counseling and refereed by your counselor for group therapy or if you'r not in counseling you will need to schedule an appointment to be evaluated for participation in the group.

Space is limited to 6 participants.

You will be notified if you are admitted into the group
You will be notified if you are placed on a waiting list should we reach capacity.

To register please complete the information below and then click the "Submit" button.

First Name *
Your answer
Last Name *
Your answer
Date of Birth *
M / D / Yr
Your answer
Email Address
Your answer
Cell Phone Number
000-000-0000
Your answer
Attends What School and Grade
Your answer
Parents Name
Mother's Name
First - Last
Your answer
Mother's Phone Number *
000-000-0000
Your answer
Mother's Email
Your answer
Father's Name
First - Last
Your answer
Father's Telephone Numer
000-000-0000
Your answer
Father's Email
Your answer
Street Address *
Your answer
City / State/ Zip *
Your answer
Current Counselor or Therapist *
Name and Telephone Number
Your answer
Credit Card Authorization: I, authorize the maintenance of valid credit card information to guarantee my chosen payment option. Charges will appear on your credit card statement as “Bevill and Associates LLC.”
Cardholder Name *
Your answer
Type of Card *
Card Number *
Your answer
Exp. Date *
Month / Year
Your answer
CVV Code *
Your answer
Billing Address *
Street - City - State- Zip Code
Your answer
Payment Guarantee: I understand that I am individually responsible for all incurred charges, even if I direct you to bill another person. If I direct charges to be billed to another person, I represent that I am authorized to give you such direction. If I have directed you to bill charges to another person who fails to make payment promptly when due, I will promptly pay on demand. I understand that if I commit to joining a weekly therapy group, In the event that I dispute a credit card charge without first trying to resolve my concern directly with Bevill and Associates LLC I agree to reimburse Bevill and Associates LLC. $25 per disputed transaction to compensate Bevill and Associates LLC for the costs incurred in trying to recover disputed funds. *
By typing your full name below indicates your agreement. *
Your answer
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