Assertiveness Group Registration Form

Thank you for your interest in our 8-week Assertiveness Group at The Well Woman.

Please complete the form below to begin the registration process. A brief screening appointment is required to ensure the group is a good fit for your needs. Once submitted, a member of our team will contact you within 1 business day to schedule your screening.

Personal Information

Full Name

Date of Birth

Phone Number *

Email Address *

Home Address

Demographic Information

Race/Ethnicity

Black/African American

White

Hispanic/Latino

Asian

Native American

Multiracial

Other

Emergency Contact Name & Relationship

Emergency Contact Phone Number

Payment & Insurance Information

How do you plan to pay?

Self-Pay ($45/session or $350 for full 8 weeks)

Insurance (subject to authorization)

Insurance Provider:

Member ID:

Group Number:

Subscriber Name (if different from participant):

Subscriber Date of Birth:

Availability & Commitment

Are you available for the full VIRTUAL 8-week program (Wednesdays, 12 PM – 1 PM, September 17-November 5, 2025)?

YES

Do you understand that missing multiple sessions may impact your progress and may result in dismissal from the group?

YES

Screening Appointment

A screening appointment is required before starting the group.

Self-pay rates: The initial screening appointment (30–45 minutes) is $75.
If using insurance, your plan may cover the screening appointment.

Consent & Agreement

Participants will be given consent forms to complete prior to initiating services.

Signature:

Clear

Date: