Registration

Group Registration Form

*All groups will run for 6 weeks at a cost of $210

A 50% Non-Refundable Deposit is due at registration with the remainder due on the first day of group.

Once you have submitted this registration form, Christine Rushford, LMHC will contact you to conduct a brief intake session over the phone, answer any questions you might have and collect your deposit.

Please Complete the Following Questions:

Which Group would you like to join? *

Name of Participant? *

First

Last

Age of Participant? *

School Participant Attends (If applicable)?

Grade of Participant (If applicable)?

Address? *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number? *

Email Address? *

Would you like to be on our email list for updates on new groups, mental health and parenting tips from Christine Rushford, LMHC? *

Preferred Method of Contact? *

Where did you hear about this group?

What would you like to learn from this group?

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Name

Group Registration Form

Please Complete the Following Questions:

Christine Rushford

LMHC, CPFT

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