Registration and Screening Form- Group Therapy - Insight Psychological Group, Westfield, Maywood, Springfield, Little Falls, New Jersey

Today's Date

Participant's Name

First

Last

Participant's Date of Birth

Participant's age

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 registering for

Click here to see more information on each group.

How did you first hear about our group courses?

IPG's Group Therapy program is open for clients who are already in their own individual therapy. Are you currently in individual therapy elsewhere?

In addition to this current form, please also fill this one out for your individual therapy.

Have you/the client ever been in any kind of group therapy in the past?

Yes
No

Do you/the client currently have any trouble with drugs or alcohol?

Yes
No

Please choose which best describes the drug/alcohol use:

Significant difficulties with drugs or alcohol, and I/we are simultaneously looking for help with it
Currently in drug/alcohol treatment
It's a problem together with the psychological issues; I don't know which is worse

Important Message:

Our group therapy program is one hour per-week and is designed as an enhancement to concurrent individual therapy. If you are currently in an IOP or PHP treatment program, our Group Therapy may be a good "step-down" solution for you once you complete the program. We will be able to review your discharge paperwork to determine if our program meets your needs at that time.

Have you/the client ever had thoughts of harming yourself or thoughts of suicide?

Yes
No

Do you/the client currently have thoughts of harming yourself or of suicide?

Yes
No

Important Message:

Unfortunately, our practice is not emergency services or urgent care. If you or your family member are currently experiencing these thoughts and feelings, call an urgent care center right away: Mobile Response 877-652-7624 will usually be able to send a team out to you within an hour. The suicide and crisis helpline is simply 988. Confidential urgent helpline for teens: 888-222-2228. And dialing 911 or just going to your nearest ER is always a safe option.

Have you/the client ever been hospitalized for psychiatric reasons or substance abuse?

Currently in inpatient treatment, looking for "step-down" outpatient group treatment once discharged
Currently in IOP/PHP (intensive outpatient treatment) and looking to continue group therapy when the program is completed
Within the past year
More than a year ago
More than 5 years ago
No

Important Message:

Our group therapy program is one hour per-week and is designed as an enhancement to concurrent individual therapy. We will be able to review your discharge paperwork to determine if our program meets your current treatment needs.

Required Participant Information

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

Client Address (open to New Jersey residents only)

Address Line 1

Address Line 2

City

State

Zip Code

Please select sex

For insurance purposes

Gender Identity

(optional)

Client Marital Status

Main 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.

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

Registration and Screening Form for Group Therapy

Important Message:

Important Message:

Important Message:

Required Participant Information

Payment/Insurance Information

Initial Appointment Request

Patient Portal Login

Update your Information

Make a Payment

Group Therapy

Need your portal password reset?

Patient Portal Login

Update your Information

Make a Payment

Group Therapy

Need your portal password reset?

Westfield

Springfield

Maywood

Little Falls