Clone of SABR Phase 1 GROUP Registration

1
Please note: If you are not currently seeing a therapist at Family Strategies, please call the office to schedule an appointment before completing the registration process.
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Full Name* This field is required.
First Name
Last Name
3
Gender
Male
Female
4
Date of Birth* This field is required.
mm/dd/yyyy
Month
Day
Year
5
E-mail * This field is required.
6
Phone Number* This field is required.
Area Code
Phone Number
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
I have completed an intake session with, and have been recommended for the SABR program by:* This field is required.
Please list therapist you met with or who you are scheduled to meet with.
9
Do you know your SAST score?
Unknown
N/A
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
SAST = Sexual Addiction Screening Test
10
Who is your current therapist?* This field is required.
Allison Kerby
Angie Hatch
Danny Bermudez
DeAnne Holden-Hall
Eric Schultz
Heather Koutsogiannis
Jacob Ybarra
John Hinson
John McLean
Julie Young
Kim Buck
Kirra Crump
Laurie Raymond
Lisette Li
Negar Bayat
Nick Miller
Rhonda Goddard
Ron Anderson
Todd Templeton
None
Other
11
I am seeking* This field is required.
Compulsive sexual behaviors and/or addiction recovery
Intimate betrayal recovery
12
Will your partner be participating?* This field is required.
Yes
No
Partner has already participated
Not applicable
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Partner's Full Name?
First Name
Last Name
14
I understand that my partner MUST register separately.
Yes, already registered
Yes, will be registering
Not applicable / partner will not be attending
15
Please briefly tell us about your situation (responses are kept confidential):* This field is required.
16
Do you have any questions or concerns:
17
Would you like to be contacted before the start of group to discuss any questions or concerns?* This field is required.
Yes
No
18
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.
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Please upload a picture of the Front & Back of your insurance card.
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Select files to upload
Max. file size: 10.6MB
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Insurance subscriber's name, as shown on the card
First Name
Last Name
21
Insurance subscriber's date of birth
Date
Month
Day
Year
22
Your relationship to the subscriber
Self
Spouse/partner
Dependent
23
There is a NON-REFUNDABLE materials fee of $25.00, per participant, that is due at the time of registration. This also reserves your spot in the group.* This field is required.
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.
24
Please select how you plan to pay for Jumpstart* This field is required.
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ORDER SUMMARY
Total costUSD
Jumpstart: Phase One Selfpay
This is the self-pay rate. $125 covers the cost of materials and the group. I understand that this is non-refundable. Should I not attend the Jumpstart, as scheduled, I will not be refunded.
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Jumpstart: Phase One BCBS
I plan to use my BCBS insurance for this one-day group therapy program. The $25 is a non-refundable materials fee.
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Jumpstart: Phase One Aetna
I plan to use my Aetna insurance for this one-day group therapy program. The $25 is a non-refundable materials fee.
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Total cost
Payment Methods
Credit Card
First Name
Last Name
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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