Interest form: RTR Group
This is a 6 week therapy group focused on Religious Trauma Recovery that will meet weekly.

Group: Religious Trauma Recovery
When: Next Cycle to begin in April , 2024 Date and time TBD
Where: Remote
Participants: 7 participants 
Facilitators
  • Sam Urena AMFT #131160/ Supervised by Rachel Brewer LCSW #97626
Cost: This group will be covered by insurance if we are in network, and cost will depend on your benefit plan.  For out of network insurance plans cost will be $50 per session (some sliding scale spots available).

We will send you a separate benefits verification form to be able to verify your insurance benefits and costs associated with your plan once you've completed this form.  Our group leader Sam will also reach out and discuss with you whether this group is right for you!
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NAME *
Your Legal Name
PREFERRED NAME
 (if different than above)
Participant's pronouns  *
 (she, he, they, other)
DOB *
Your Date of Birth 
MM
/
DD
/
YYYY
PHONE
 *
Your phone Number
EMAIL  *
Email where we can reach you 
Address *
Your home address 
Challenges I'm currently having  *
Required
Therapy *
Are you currently in individual Therapy?
INSURANCE & FEES
Insurance *
What type of insurance do you have?  Please note here if you have more than one insurance plan.  (For this group we are in network with Cigna, Anthem, Anthem UCSHIP, Cencal, and Aetna) if we believe we are in network with the insurance you select, we will send you a follow up insurance form to fill out. *Please note that you may have a deductible or copay amount through your insurance plan as well for group services. 
Cost *
If Rose Wellness is not in network with my insurance I am able to pay the following ;
Required
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