SABR Phase 1 GROUP Registration

SABR - PHASE 1 IN-PERSON GROUP REGISTRATION

PLEASE NOTE: A SABR assessment MUST be completed at Family Strategies Counseling BEFORE registering for SABR. Additionally, ALL participants must work with a Family Strategies SABR therapist while in the SABR class. If you do not already have a SABR therapist, please contact our office to schedule a session with one (Telehealth and phone sessions available). See our website for a current list of SABR-approved therapists.
Client Information
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
mm/dd/yyyy
E-mail *
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Payment Information
How do you plan to pay for SABR Phase One?*

Self-Pay ($325.00 will be collected at check out, in addition to the materials fee to cover the cost of group)(BCBS OR AETNA ONLY) Insurance (deductibles, coinsurances & copays will apply)
PLEASE PROVIDE YOUR INSURANCE INFORMATION BELOW

You will be contacted, via the email address you provided, by someone from our billing department within the next two (2) business days to go over your out of pocket cost after your insurance is applied. Any amounts not covered by your plan will be required to be paid before the first night of group.
Please upload a picture of the Front & Back of your insurance card.

Browse Files

Cancelof
Insurance subscriber's name, as shown on the card

First NameLast Name
Insurance subscriber's date of birth

MonthDayYear
Date
Your relationship to the subscriber

SelfSpouse/partnerDependent
PLEASE NOTE: A Phase One Group No-Show Fee of $81.25 will be charged to your card on file for any nights that you do not attend. We cannot bill your insurance unless you are in attendance.
There is a NON-REFUNDABLE materials fee of $75.00, per participant, that is due at the time of registration. This also reserves your spot in the group.*

I understand by paying for the materials now I am reserving my place in the next group. I will not be refunded if I do not attend group.
Total Cost of Registration*

Total Amount Due at Registration*

USDDescription

Credit Card

Apple Pay

Google Pay

SABR - PHASE 1 IN-PERSON GROUP REGISTRATION