I am registering to participate in the Mind Therapy Clinic outpatient group(s) named below.

*Standard rates are $350.00 per month per group for groups that meet weekly.

My signature below confirms my intention to enroll in the group(s) named above. I understand groups are billed and paid for on a monthly basis. In this way my spot in the group is held for me until such time I give notice of my intention to terminate. Such notice must be provided one week before the end of the calendar month in order to give the group time to process the change in group composition. I further understand my enrollment in the group is ongoing until I provide such notice.

Name *
Name
Start Date
Start Date
I'm enrolling in the following Groups
$
Client Signature
Client Signature
I agree to an electronic signature.
Signature Date
Signature Date