Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Consent to Contact & Verify Insurance *

I authorize ACTS Care to contact my insurance provider to verify coverage for group therapy services and to contact me with the results.

Yes

No

Consent to Electronic Communication *

I understand that ACTS Care may use secure electronic communication to send forms, updates, and group information.

Yes

No