Group Therapy Interest Form

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Thank you for your interest in group therapy! If you are interested in getting started or learning more information, please fill out the form below 👇

Please make sure to watch this video (click link) to learn more about therapy services through Dr. Tay Concierge Clinical Care. This will answer many of the questions you may have about the process and you can include any follow-up questions below.

Group therapy includes:

- Weekly group-based calls with 1:1 support for each family via a parent coaching model - currently on Thursdaysat 11:30am EST. Sessions are typically 1.5-2 hours. If you cannot attend live, you can pre-submit questions and watch the recording

- Unlimited support in between sessions via our group chat

- Care coordination with your child's other providers / school as determined clinically necessary, which may include email support and brief phone calls

- A community of like-minded autism parents

The cost is $497/month, with an initial 3 month commitment.

Your full name *

What is your relationship to the child? *

Parent

Legal guardian

Other:

Phone number *

Email *

What is your preferred method of contact? *

Texting

Either is fine!

Home address (please include the state you reside in) *

Child's full name *

Child's date of birth *

YYYY

Does your child have an autism diagnosis? *

Yes, my child has an autism diagnosis.

No, my child does not have a formal diagnosis, but I have concerns about autism.

Other:

Tell me about your child - what are your biggest questions and concerns? What are your goals for your child and family life? *

Outside of group therapy, are there any services / support you are needing for your child?

How did you hear about us?

What is your interest level? *

I have learned enough and am ready to enroll my family!

I am very interested but have questions first

I am just in the information gathering stage

Check if you are interested in learning about add-on 1:1 services that allow you individual access to Dr. Tay and/or another provider on the Dr. Tay team.

Yes please

Please list any questions or additional information. Dr. Tay and/or a member of our team will follow up with you to answer your questions or get your enrolled. Expect a response within 24-48 hours on weekdays.

I acknowledge that this is a concierge-based practice and all services are private pay. I understand I can request a superbill to submit to my insurance for potential reimbursement if I have out-of-network coverage.
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Yes

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