Registration for Healthy Minds Group Therapy

Today's Date *

Participant's Name *

First

Last

Participant's Date of Birth *

I'm filling this request out for *

Myself
My partner
My child
Other

Your Name *

(required if filling out the form for someone else)

What is your relationship to the group participant? *

Your Email *

Select which group(s) you or your child are interested in joining *

Tell us more about your interest in the group(s) you checked above. What are you looking to draw from the experience? *

How did you first hear about our group courses?

Are you currently a patient at IPG? *

What's your therapist's name?

As mentioned, our Group Therapy program is open for clients who are already in their own individual therapy. Please provide us with some information regarding the therapy you are currently in:

Name of your therapist

Their contact information (If there is a need for us to contact them, you will be asked to sign a separate Release of Information form first).

How long have you been in therapy with them?

You may click submit, and your application will be reviewed and forwarded to the group coordinator.

Required Participant Information

Since you are a new client, the fields below are required in order to enter you into our software.

Client Address *

Address Line 1

Address Line 2

City

State

Zip Code

Client Gender *

Client Marital Status *

Main Phone *

Emergency Contact *

First

Last

Phone *

Payment/Insurance Information

How will you be paying for treatment? *

Client's relationship to primary insurance holder *

Self
Spouse/Partner
Child
Other

Name of primary insurance holder *

Date of birth of primary insurance holder *

Subscriber/Member ID# *

Primary Insurance Company *

Please upload a copy/pic of your insurance card (front) *

Click or drag a file to this area to upload.

PNG, JPG, JPEG, DOC, or PDF Format Only

Please upload a copy/pic of your insurance card (back) *

Click or drag a file to this area to upload.

PNG, JPG, JPEG, DOC, or PDF Format Only

Check if you are unable to upload your insurance cards.

If you are unable to upload a picture of your insurance cards, then after submitting this form you will need to email them to appointments@insightpsychgroup.com in order for our offices to review your registration.

We’re excited to have you!

Please use the form below to express interest and apply to one or more of our group courses. You will be contacted shortly afterwards to answer any questions you may have and learn the next steps (consent to participate, payment authorization, etc.)

Required Participant Information

Payment/Insurance Information

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Little Falls