Substance Abuse Groups - Grace Health Services LLC

Thank you for your interest in our substance abuse group therapy sessions. We are here to provide the help and support you need on your recovery journey.

To sign up for a group therapy session, please follow the steps below:

  1. Fill out the form: Please provide your name, contact information (email and phone number), and any other relevant information requested in the form.

  2. Submit the form: Once you have filled out the form, click the "Submit" button to send your information to us.

  3. Wait for a response: We will review your form and get back to you as soon as possible to schedule an appointment for a group therapy session. We will contact you via phone, SMS, or email (as provided in the form) to confirm the details of your appointment.

Thank you for taking the first step towards recovery. We look forward to supporting you on your journey.

First Name: *
Last Name: *
Gender: *
Phone Number: *
Please provide your phone number so that we can contact you to schedule an appointment for a substance abuse group therapy session. We may use this number to send you an SMS or to call you to confirm the details of your appointment.

Email address: *
We may use this email address to send you confirmation of your appointment or to provide other relevant information.
Date of Birth: *
Please provide your date of birth so that we can accurately assess your eligibility for our substance abuse group therapy sessions. This information will be kept confidential and will not be shared with any third parties.
MM
/
DD
/
YYYY
Availability:  *
Please note that space is limited and availability is on a first-come, first-served basis. We will do our best to accommodate your availability, but please understand that we may not be able to accommodate all requests.
Payment: *
Provider:
Select your insurance company name: 
IF you've chosen Self-pay please skip this question. 
Member ID/ Policy #:
IF you've chosen Self-pay please skip this question. 
Group ID: (Optional)

DISCLAIMER: 
The information that you provide in this form will be used to schedule an appointment for a substance abuse group therapy session. Your information will be kept confidential and will not be shared with any third parties except as necessary to schedule and facilitate your appointment.

By submitting this form, you acknowledge that you have read and understand this disclaimer and agree to the collection and use of your personal information as described. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Grace Health services llc. Report Abuse
Google Forms