Chronic Conditions Support Group - Counseling Associates

Telehealth group offering for adults 18+ living with chronic health conditions and seeking a supportive environment.

Most insurances will cover the cost of group sessions.
Speak to our Group Coordinator for questions regarding insurance or self-pay rates.

Sessions will be conducted via Zoom

To inquire further about groups, please contact our Groups Coordinator at 603-865-1321 option 3.

Who is completing this request? *
Your name
Agency name
Agency Phone Number
	(do not include 1- prefix)
Agency E-Mail
Is the individual aware you are referring them to this group?	Yes No Please choose yes or no
May we contact you regarding this referral if needed?	Yes No Please choose yes or no
Why are you interested in this group?
Participant First Name *
Participant Last Name *
Date of Birth * (mm-dd-yyyy)
Address*
Parents Name (if Client under 18)
Communication Preference	Phone Email Please choose yes or no
Phone *
	(do not include 1- prefix)
OK to Leave Message *	Yes No Please choose yes or no
E-Mail
Do you have Health Insurance ? *
Insurance Carrier *
Insurance ID# *
Secondary Insurance
ID Number
How did you hear about this Group? *
If you were referred to this Group, who referred you? *
(* required info)