Teen Group Signup Please enable JavaScript in your browser to complete this form.Teen Name *FirstLastParent/Guardian Name *FirstLastGuardian Email *Teen Email (if they have one)Date of Birth *Please enter your teen’s date of birth in MM/DD/YYY formatWhat Day Will Your Teen to Attend? *Tuesdays 7:00PMThursdays 7:00PMHow Would You Like to Pay? *Self Pay – $40 per sessionInsurance – AetnaInsurance – Blue CrossInsurance – CignaInsurance – United/UMR/UBHInsurance InformationIf you chose insurance, please enter the teen’s insurance ID Tell Us About Your Teen *What is bringing your teen into therapy at this time?Submit
