Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

May we leave a voicemail at this phone number? *

Yes

No

How do you prefer to be contacted? (select all that apply) *

Email

Phone

I understand that ICRC is a private pay practice and does not bill or submit claims to any insurance companies. *

I Agree

I understand that the cost of this group is $50 per 60 min session *

I Agree

I understand that participation in all 5 group sessions is important and I will do my best to attend all sessions. *

I Agree