Registration Form

Full Name

Date of Birth

Phone

Insurance Name

Member ID#

In a few sentences, please provide a brief description of what is supporting your curiosity to participate in this program, and what you are most hoping to learn from it

If working with a therapist, please share their name

I give consent to my treating providers within Savera to share treatment information for care coordination purposes. This may include review of your health care records at Savera and/or collateral communication between treating providers at the practice (e.g., individual therapist and group therapy facilitator; current and former therapists; therapist and psychologist who might be performing a psychological/neuropsychological evaluation for you)

Once you submit this form, our office will reach out to you with confirmation and information about your insurance coverage

Thank you for registering!

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