Parent Group Registration

PARENTING YOUR GIFTED CHILD: GROUP REGISTRATION *

Groups are limited to 10 participants. If a group is full, you will be notified via email and placed on a waiting list. Cost is $450 for one caregiver or $675 for both caregivers.

8 Thursdays, 7:00pm - 8:30pm, January 9 - February 27, 2020

Caregiver #1 Name *

First Name

Last Name

Caregiver #1 Primary Phone *

(###)

###

####

Caregiver #2 Name

First Name

Last Name

Caregiver #2 Primary Phone

(###)

###

####

Group Participants *

Caregiver #1

Caregiver #2

Both caregivers

Child #1 Name *

First Name

Last Name

Child #1 Date of Birth *

MM

DD

YYYY

Child #2 Name

First Name

Last Name

Child #2 Date of Birth

MM

DD

YYYY

Child #3 Name

First Name

Last Name

Child #3 Date of Birth

MM

DD

YYYY

Financial Agreement *

PAYMENT IN FULL IS DUE WHEN INVOICE IS RECEIVED. All invoices are sent via email. Please select preferred form of payment below.To keep the cost of services down, check is the preferred form of payment. A 3% convenience fee is automatically added to credit card payments made online. Invoices are sent via email and payment in full is due when invoice is received unless prior alternate arrangements have been made. Credit card information is required for registration fee and security of payment. I understand that Square Pegs does not offer refunds, missed sessions cannot be rescheduled, and fees cannot be prorated. I acknowledge that I am financially responsible for the complete payment of all charges to Bloom. I understand that I am obligated to pay registration fees and non-sufficient funds fees, and that these fees are not reimbursed by insurance companies. I acknowledge and understand that a $35.00 service fee will be charged for any checks or payments returned for insufficient funds. I understand that finance charges will accrue at 12% APR if payment is not received in our office within 5 days of the due date, and a minimum monthly finance charge of $5.00 will apply to all overdue payments. I understand that if my account is 30 days past due, Bloom will automatically charge the credit card on file to cover my outstanding balance. Balances exceeding $1000.00 will result in services being placed on hold until a payment plan has been established. Bloom reserves the right to terminate treatment if payment for services is not received. Invoices more than 90 days past due are considered to be in default. I understand that I will be charged cost recovery fees if Bloom must take collection action to resolve payment delinquencies. Cost recovery fees may include small claims fees, attorney fees, enforcement fees, collections fees and lien fees. I attest that I have read, understand, and agree to the terms of the financial responsibility policy as detailed above.

Confidentiality Agreement *

I understand that confidentiality is the shared responsibility of all group members and group facilitators. I understand that although group facilitators do not disclose group communications or information, group members’ communications and information are not protected. I understand that this agreement is an attempt to provide group members with as much confidentiality protection as possible. I agree that I will not disclose private information shared by members of the group. I agree that I will not discuss any information pertaining to any group member in any place where it can be overheard by anyone not directly involved with the group. I agree that that I will not disclose to anyone outside the group any information that may help to identify another group member. This includes, but is not limited to, names, physical descriptions, biological information, and specifics to the content of interactions with other group members. I agree that I will not release any information, in writing or orally, regarding any group member to any person(s) or agencies.

Method of Payment *

Please select payment method below. To keep the cost of services down, check is the preferred form of payment. If credit card is selected, you will receive an invoice by email to pay online. A 3% convenience fee is automatically added to credit card payments made online. Registration is not confirmed until payment in full is received.

Check (mail to: Bloom Pediatrics, 1523 Wellesley Avenue, Los Angeles, CA 90025)

Credit card (paid online: Visa, MasterCard, or American Express)