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Reclaiming Politics: Registration Page
Full Name
(Required)
First
Last
Legal Name
If your legal name is different than the one you use, please enter it here. This is only for insurance purposes.
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender Identity & Pronouns
(Required)
Email
(Required)
Enter Email
Confirm Email
Phone
(Required)
May we leave a voicemail at this number?
(Required)
Yes
No
Will you be self-pay or using insurance benefits?
(Required)
I will be self-pay
I will use insurance
Who is your insurance provider?
(Required)
Ex: BCBS, Midland's, UHC, Medicaid. If we do not have your insurance on file already, please be prepared to share your card for eligibility & benefits verification.
Do you currently have an individual therapist?
(Required)
Yes
No
Therapist's name
(Required)
Therapist's contact information (phone or email)
(Required)
Two-Way Authorization of Mental Health Information
(Required)
By selecting the button below, I consent to the exchange of mental health information between group facilitators and my individual therapist for the purpose of continuity of care. I understand that I can revoke this authorization at any time in writing.
I agree to the exchange of information
What do you hope to learn or gain from this group?
(Required)
Conditions of Participation
(Required)
This group is open to a diverse population of individuals which means political identities of other group members may differ from your own. Participation in this group requires each individual to be aware of diverse thought perspectives prior to joining. The goal of the group is not to find "common ground" or switch others' views, but to equip group members with skills and abilities to cope and communicate across the political spectrum.
I agree to and understand the conditions of participation.
