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Anger Management

Crisis Group Workshop

intensive-outpatient-treatment

Terms & Conditions

INSURANCE VERIFICATION

Please fill out the following form to help us verify your health insurance.

First Name *

Last Name *

Email Address *

Phone *

Date of Birth *

Street Address

City

State

Zip

Primary Insurance First Name *

Primary Insurance Last Name *

Primary Date of Birth *

Insurance Provider Name *

Provider Services Phone

Plan Type *

Insurance Policy Number *

Group Number *

I declare that the info I’ve provided is accurate & complete

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Total Life Change

1300 East Shaw Avenue || Suite 121 || Fresno, CA 93710

(559) 475-9779

Certified by the State Department of Health Care Services

Copyright 2024 - Total Life Change!

PROGRAM FEEDBACK

FIRST NAME *

LAST NAME *

PHONE *

EMAIL *

ADDRESS *

DATE OF BIRTH *

GENDER *

ETHNICITY *

1) Did the Crisis Group help you in understanding your codependency?YesNo

2) If Yes, do you find yourself better understanding where you need to change:YesNo

3) Each week we went over different lessons, do you find yourself understanding to a point of wanting to make changes in your life?YesNo

Which lessons did you get the most out of? (Select all that apply)

Fact Sheet on CodependencyCodependency Progression CurveJelnick ChartAddiction Education: Addicts Resist PressureUnderstanding Addiction & CodependencyI’m Not My Fault: Understanding the “Why”Karpman TriangleMoving Beyond Codependency10 Laws of BoundariesRed Light/Green LightKeys to Assertive Communication & BoundariesCodependency Caretaking

OVERALL EXPERIENCE * *

RATE PROGRAM

Please keep my feedback anonymous.I understand that this information may be used for program analysis.

TESTIMONIAL SUBMISSION

FIRST NAME *

LAST NAME *

PHONE *

EMAIL *

DATE OF BIRTH *

ADDRESS *

REASON FOR INTAKE *

AlcoholOpiates [Pills]Opiates [Heroin]AmphetaminesBenzodiazepineMarijuanaOtherN/A

PROGRAM PARTICIPATION *

Intensive Outpatient ProgramCodependency Family GroupCrisis Group WorkshopAnger ManagementAssessment/CounselingOther

GENDER *

ETHNICITY *

ANNUAL INCOME *

RATE PROGRAM

GROUP LEADERSHIP

INTAKE PROCESS

COUNSELING

PROFESSIONALISM

COMMUNICATION

OVERALL EXPERIENCE *

Please keep my feedback anonymous.I understand that this information may be used for program analysis.

Family Sign-Up

Family members of program participants can sign-up to receive program updates.

First Name *

Last Name *

Email Address *

Phone *

Name of family member in program *