Welcome to Group!

Participant's Name *

First Name

Last Name

Participant's Cell Phone *

For participants who are 18 or under, use parent's cell phone number.

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I agree to the Term of Service outlined here: *

I (or my child or dependent) am committing to enrollment for six months of Group Therapy at Mindsoother Therapy Center to be charged one time every 4 weeks for the duration of the group. I understand that this payment is non-refundable and that refunds will NOT be provided for payments already made. I understand that I can terminate my enrollment (or enrollment of my minor child or dependent) by providing WRITTEN notice to danna@mindsoother.com or to Danna Markson, LCSW. Mindsoother Therapy Center. 2 West Northfield Road, suite 211, Livingston, NJ 07039. Once written notice is received, I will be released from my enrollment and financial obligation starting with the NEXT payment period. Please note: As group therapy spots are limited, this policy ensures that clients enrolled in group are committed and attending. Thank you for your understanding of our policy.

I agree