Name

Name of Parent (youth groups only)

Phone

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which Group

Desired Amount of Payment

Group cost is anywhere from $10-40 per session, we trust you to choose an amount that you can pay The goal is to be accessible to all in need

Terms & Conditions

Group will be charged monthly at the beginning of each month

Clients will be asked to put a credit card on file to allow for automatic charges, it is your responsibility to request alternate payment arrangements

It is the client's responsibility to identify if they will miss any groups for the upcoming month BEFORE the monthly fee is charged, and there is no charge for those sessions provided they are identified before the first of the upcoming month

There are no refunds for the monthly charged amount after payment for the upcoming month, as it is used to hold a seat in the group each week

Enter your full name below

I understand that this field represents an electronic signature and permission for me (or my child if applicable) to receive counseling, coaching, or psychoeducational services from Innovate Mental Health Solutions, LLC

Group intake