Registration for Healthy Minds Group Therapy 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.) Please enable JavaScript in your browser to complete this form.Today's Date *Participant's Name *FirstLastParticipant's Date of Birth *I'm filling this request out for *MyselfMy partnerMy childOtherYour 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 *DBT Skills Group (Adults)Adult Anxiety Group (Enrolling)Teen Anxiety Course (ages 13-17) (on hold)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?Friend or colleagueOnline AdWeb searchSocial MediaOtherAre you currently a patient at IPG? *Please selectYesNoWhat's your therapist's name?You may click submit, and your application will be reviewed and forwarded to the group coordinator. Required Participant InformationSince you are a new client, the fields below are required in order to enter the participant into our software.Client Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClient Gender *Client Marital Status *SingleSingleMarriedDivorcedSeparatedWidowedOtherMain Phone *Emergency Contact *FirstLastPhone *Payment/Insurance InformationHow will you be paying for treatment? *I need to stay in my insurance networkI would like to use my insurance, but am willing to go out of network if necessaryFee-paying. I don't want to use my insuranceClient's relationship to primary insurance holder *SelfSpouse/PartnerChildOtherName 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, DOC, or PDF Format OnlyPlease upload a copy/pic of your insurance card (back) * Click or drag a file to this area to upload. PNG, JPG, DOC, or PDF Format OnlySubmit