InnerBalance Health Center Family Program Sign-up Form Session Date*Choose session dateJanuary 5, 6, 7 of 2017February 2, 3, 4 of 2017March 2, 3, 4 of 2017March 30, 31, April 1 of 2017April 27, 28, 29 of 2017May 25, 26, 27 of 2017June 22, 23, 24 of 2017July 20, 21, 22 of 2017August 17, 18, 19 of 2017September 14, 15, 16 of 2017October 12, 13, 14 of 2017November 9, 10, 11 of 2017December 7, 8, 9 of 2017[NOTE: a 3 person minimum enrollment in required in order to hold the class. If the minimum enrollment has not been met within 1 week of the program date, the class will be cancelled.]Patient Name* First Last If your loved one has been or is currently a patient/client of InnerBalance Health Center, please provide their name:To maximize the effectiveness of our family program, it is helpful to learn more about each attendee and what they hope to achieve. Please complete the form below so we can best serve you.Attendee Name* First Last Attendee Phone #*Attendee Email* Date of Birth* If under 17, please call us to discuss appropriateness.Relationship to Patient*Known Food Allergies?No Allergies* I have no Known Allergies Health of Relationship*Select a rating from 1-101 - Extremely Unhealthy2 - Very Unhealthy3 - Unhealthy4 - Slightly Unhealthy5 - Neutral/slightly unhealthy6 - Neutral/slightly healthy7 - Slightly Healthy8 - Healthy9 - Very Healthy10 - Extremely HealthyPlease rate your relationship with the addicted person on a scale of 1-10.Goals & Expectations*What are your goals and expectations for the Family Program?Limitations*Do you have any physical limitations or medical conditions? type 'none' if you have no limitations.Drugs / Alcohol Use*NoYesDo you feel you have a dependence on drugs or alcohol?Please Explain*Drug & Alcohol Free*Attendees must be alcohol and drug free for the duration of the 3-day Family Program unless you are taking medications prescribed by your physician. I Agree Refund Policy*Family Program attendees are eligible for a refund (minus a 10% processing fee) if notice is given at least 48 hours prior to the scheduled class date. There will be no refunds if less than 48 hours notice is given, but we encourage you to attend the next scheduled class. If an attendee is dismissed from the program for inappropriate behavior, no refund will be given. I Agree Costs All treatment programs include one complimentary admission for a Primary support member of your choice and $800 for each additional participant. This includes 3-days of training and education, lunch and snacks. Participants will be responsible for their own lodging, transportation from the airport to the facility, transportation back to the airport and any additional meals. Please list the attendees for your group below and indicate who is the Primary Participant. If you are the only attendee, then list yourself as the Primary Participant.Primary Participant #1If you are the primary participant, list your name here. If you are a secondary participant, please list the Primary Participant of the group here and list your name as a secondary participant below.Secondary Participant #2Secondary Participant #3Secondary Participant #4Secondary Participant #5Family Program Fee Price: $0.00 If someone else is submitting a payment or there is no payment due, please leave the credit card information empty.Credit Card #Expiration Month*Select Month01 January02 February03 March04 April05 May06 June07 July08 August09 September10 October11 November12 DecemberExpiration Year*Select Year2016201720182019202020212022202320242025Security Code (CVV)*Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NOTE: The InnerBalance Family Program is intended to help support members learn about the challenges of addiction and become better equipped for helping their loved ones transition to a life of sobriety. We encourage active participation and interaction with other members participating in the program. To fully engage in the family program, we discourage visits with those currently in treatment due to the distracting nature for all parties involved.