Central Texas Child and Family Counseling Group Registration Request

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We're excited about your interest in participating in a 5-week group this summer.

Completion of this form is a request and does not guarantee a spot in the group.

A spot guarantee will occur after your non-refundable payment in full is received. Limited spots are available per group and will be filled on a first come first serve basis. After completing this form, you will be contacted via email and given more details about your group, securing your spot and payment steps through our client portal.

We are thankful for the opportunity to work with you.

Which group are you interested in registering for? *

Parents of Preschoolers Group: Led by Lauren Gibson, LMFT (5 Sundays, starting July 7th 2-3:30 pm)

Transition to Middle School for GIRLS: Led by Christine Vick, LPC (5 Wednesdays, starting June 19th 9-10:30 am)

Transition to Middle School for BOYS: Led by Christine Vick, LPC (5 Wednesdays, starting June 19th 11:00 am-12:30 pm)

Express Yourself for Girls ages 14-17 struggling with anxiety: Led by Christine Vick, LPC (5 Wednesdays, starting June 19th 3:30-5 pm)

Teacher Happy Hour Reboot: Led by Christine Vick, LPC (Wednesdays, starting June 19th 6-7:30 pm)

Required

Group Participant's name (first and last) *

Are you a current or former client of Central Texas Child and Family Counseling? *

Yes

If you answered yes to the question above, what is the person's name associated to the client portal account you have with us.

For participants under the age of 18, please list the name of a parent or guardian. If you are registering yourself and are 18 years of age, please enter 'n/a' *

Contact email for self (if 18 or older) or for parent/guardian (for minors). *

I understand that my (or my child's) spot in the group is held and reserved for the duration of the 5 weeks the group runs. The cost is the same regardless of attending all sessions or not. This group is offered at $45 for each 1.5 hour group session, which comes out to $30 per hour or $225 for the full 5 weeks. The total cost must be paid in full prior to the start of the group. Payments can be made in one full payment at registration or in two payments, for a $10 added fee: $135 at the time of registration and $100 invoiced 1 week before the first group session. All payments are non-refundable with no exception. Failure to complete payment within 48 hours of the first group session may result in loss of your spot. *

I understand and give consent. I would like to be invoiced the full amount.

I understand and give consent. I would like to be invoiced $135 now and $100 later. I understand I will loose my spot if I do not complete all payments 48 hours or more in advance to the start of the group.

I understand that I completing this form does not guarantee a spot in the group and that I will be contacted via email prior to the start of the group either way with registration information.

Once registered, the leading counselor will contact me via email with additional details about the group.

I understand that I will be responsible for the full balance of the group when the invoice is received. Failure to make payment in a timely manner could result in losing the spot in the group. The total cost for participation in all sessions of our groups is $225 if paid upfront or $235 if paid in two payments. This includes 5 sessions. Missed sessions will not be reimbursed. Paid registrations is non-refundable or transferable if you should not be able to attend.

I understand and give consent to be emailed and invoiced.

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