Cognitive Behavioral Therapy Crash Course Name* First Last Gender* Required for insurance billing purposes.Date of Birth* Required for insurance billing purposes.Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email How will you be paying for these sessions?* Private pay, $20 per session Health Insurance Who is your health insurance provider? If you are able, can you please upload a copy of the front and back sides of your insurance card?Max. file size: 128 MB.Is there anything you would like the group facilitators to know in advance of the first group?NOTE: This information is confidential and is only for the group facilitators.
