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Refuge Cove Counseling, LLC

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- STEPHANIE STAVELAND, LCSW
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INTERESTED IN JOINING A GROUP?

PLEASE SIGN UP BELOW AND STEPHANIE WILL CONTACT YOU FOR A PRE-SCREENING PHONE CALL AND REGISTRATION.

Groups are currently meeting IN-PERSON in Wasilla, Alaska; if you are interested in a telehealth option for those of you residing around the State of Alaska, please feel free to fill out the form and request a telehealth option.

Group Therapy Interest Form

First name*

Last name*

Email (to be used for a client portal account)*

Phone*

I give permission for the following contact:*

Call

Leave Voicemail

Text Message

Email

Which group are you interested in attending?*

I understand I must complete a pre-screening intake interview and commit to attending all group sessions. *

Yes

No

For payment I will be utilizing:

Insurance

Self Pay

If you are uninsured, what are you able to afford at this time?

I am feeling financially stable and can afford full price ($50/session card transaction or $40/session cash pay)

I am experiencing some financial difficulties and am requesting half price ($20/session cash)

I am experiencing financial hardship and can afford $10/session cash pay.

I would like to discuss availability for a full scholarship to attend.

How did you hear about us?*

If you reside outside of the Matsu-Valley and are interested in a telehealth option please indicate below.

Yes, please offer a telehealth group option

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