CASICS student registration
Please complete and submit the pre-registration information below. Additionally you may submit payment using this form or pay later by phone or at Connections Counseling main clinic. After pre-registration, you will be contacted (initially by email, also by phone if necessary) to schedule your first individual session.
Email address *
First name *
Your answer
Last name *
Your answer
Gender
Mobile phone number *
Your answer
Home or other phone
Your answer
Date of birth *
MM
/
DD
/
YYYY
Student ID *
Your answer
CASICS completion deadline
MM
/
DD
/
YYYY
Year in school
Educational Institution *
Campus address street *
Your answer
Campus address city *
Your answer
Campus address zip code *
Your answer
Have you completed CHOICES about alcohol group previously?
Have you completed individual BASICS (alcohol) previously?
Was alcohol involved in the current incident?
Were you referred for CASICS+ (marijuana and alcohol) *
Referred by *
Name of referring individual
Your answer
Referring individual email address
Your answer
Ethnicity self-identification (voluntary)
Billing
Payment must be made before first session. Provide your VISA or MASTERCARD information to charge session cost of $125. Following registration and payment you will be contacted by Connections Counseling to schedule your first individual BASICS session. First contact will be by email. Payment may also be made by telephone (608-233-2100 x-0 Mon-Thur 9 am to 7 pm and Friday until 3 pm) or in person at Connections Counseling LLC, 5005 University Ave, Ste 100, Madison 53705.
Credit Card Type
Card number
Your answer
Credit card expiration month
Credit card expiration year
CCV code on back of card
Your answer
Billing name if not in your name
Your answer
Billing zip code if not your campus address
Your answer
Any addition information we should know? Include schedule preference (day of week, time of day)?
Your answer
Connections Counseling LLC
Main clinic: 5005 University Ave, Ste 100, Madison WI 53705
Campus: 660 West Washington Ave, Ste 308, Madison WI 53703
608-233-2100
info@connectionscounseling.com
A copy of your responses will be emailed to the address you provided.
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