Registration: Regroup Therapy

If you have already registered for access to our online scheduling system and you have already received your welcome email message with your temporary password, please sign in using that password. 

If you have not completed this form, thank you for taking a moment to complete and submit the following details.

Thank you for your patience, it might take a few hours or days until your registration has been processed.


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APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Program description (Ex. inpatient/outpatient, population served, etc.)

Services Needed
Prescriber (select all acceptable)
MD
APN
Medical Resident
Nonprescriber (select
LCSW
LCPC/LMFT
LSW (trainee)
Total hours needed

Preferences
Preferred Days
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Monday Preferred Hours (if applicable)
Tuesday Preferred Hours (if applicable)
Wednesday Preferred Hours (if applicable)
Thursday Preferred Hours (if applicable)
Friday Preferred Hours (if applicable)
Saturday Preferred Hours (if applicable)
Sunday Preferred Hours (if applicable)

Billing Info
Billing Needs
Medicaid
Medicare
Private payers
Notes

Misc.
Additional Languages Needed
ASL (Sign Language)
Arabic
Chinese
Dutch
Farsi
Finnish
French
German
Greek
Hebrew
Hmong
Indian (Hindi/Urdu/Misc)
Italian
Japanese
Polish
Portugese
Russian
Spanish
Somali
Swedish
Tagalog
Thai
Vietnamese
Other



We appreciate your time and interest


 
 
Chicago, Illinois 60640
860-539-9019
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