S.A.B.R. - Sexual Addiction & Betrayal Recovery

*Please note that spouses must enroll separately.                                                                                                                                                                                                 

**There is no charge to repeat the enrollment group (Phase One), unless you need new workbooks ($95).**

PLEASE NOTE: Prior to enrollment ALL participants must complete an intake assessment with a Family Strategies SABR therapist, which includes the SAST.  This therapist must recommend the enrollment.

PLEASE DO NOT ENROLL FROM A MOBILE DEVICE. REGISTRATIONS PERFORMED VIA MOBILE DEVICES OFTEN DO NOT PROCESS COMPLETELY.
I have completed an intake session with the following therapist, and have been recommended for this program (required)	:	Please SelectFloyd GodfreyKim BuckJohn HinsonAngie HatchMatt WheelerJohn McLeanEric SchultzBrittany JohnsonJulie YoungErik JohnsonDebbie McRaeThomas Olsen
SAST Score	:	Please select1234567891011121314151617181920Not Completed
First Name	:
Last Name	:
Date of Birth	:
Email	:
Phone	:
Street Address	:
City, State & Zip Code	:
My current therapist:	:
Do you have Blue Cross Blue Shield Insurance?	:	YesNo
If yes:
Member ID Number:	:
Group Number:	:
Primary Insured Full Name:	:
Primary Insured Date of Birth:	:
Please select if you are registering for SABR or TRIBE	:	Please SelectTRIBE (18- 24 y/o singles)SABR/LifeSTAR
You are the	:	AddictSpouse
Will your partner be participating?	:	YesNoNot this timeNot Applicable/no partnerPartner has already Participated
If applicable, What is your partner's name	:
I understand that my partner MUST register separately.	:	Yes, they will or did already register separately
Please tell us about your situation Your response will be kept confidential	:
Do you have any questions or concerns?	:
Would you like to be contacted before the group to discuss questions or concerns?	:	YesNo
Please print this form and bring it to group on the first night	:
I have completed the form above and will email a scanned copy to the office (admin@familystrategies.org) or bring it on my first night of group.	:	I have emailed the form to admin@familystrategies.org  I will bring the form, filled out to group on my first night.
I understand that the form above is used for the monthly billing of my participation in the program, and this card will be charged $220 per participant on the first of each month for the month. (Clients using Blue Cross Blue Shield will be billed according to their plan)	:	Yes, Family Strategies has my permission to charge my card on file for group charges on the first of each month.