Healthy Single Men: Support at Guillaume Counseling

Healthy Single Men

Demographic

First Name

Middle Name

Last Name

Date of birth (must be 18 years old or older)

Cell Phone Number

Address

Home Address

City

State

Zip Code

Emergency Contact

Full Name

Relationship

Phone Number:

Group Classes Options

Which Group(s) are you registering for? Check all that applies and pay the appropriate fee for each , separately

Healthy Parenting, 0-2 Years Old

Healthy Parenting, 3-12 Years Old

Healthy Single Women

Healthy Single Men

Healthy Married Couples

Healthy Finances: Managing Financial Stress

Healthy Men's Group: Managing Anxiety, Depression, and Stress

Healthy Women's Group: Managing Anxiety, Depression and Stress

Hourly Individual Consultation - available only after you have attended 4 group classes. You may pay for this service when you initially register or later.

Preferred times (check all that applies)

Insurance information (For residents of California, Texas, or Oregon paying with medical insurance)

Insurance carrier

Insurance ID#

Insurance Group #

Policy holders full legal name

Policy Holder’s date of birth

Policy holders phone number:

Provider/Customer number as it appears on your insurance card

Our office will contact you within 24-48 hours upon receiving your payment. If you are paying with insurance, we will register you in our Client Web Portal and schedule you for an initial mental health assessment with a Clinician.

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