480-668-8301
1745 S. Alma School Rd Suite 230
Mesa, AZ 85210
  Toll Free: 1-800-614-8142

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)
SAST Score :
     
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? :
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 :
     
You are the :
Will your partner be participating? :
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? :
  

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.