Group Enrollment | Lizotte Clinical, LLC

Group Enrollment Note: Groups have limited seats per module. After you submit, our team will contact you to confirm fit, the next available start date, and your group schedule. After your referral is submitted, you will receive a link to the Jane portal to create a profile, and payment will be collected there.

1Group Selection

Which group(s) are you enrolling in? *

Youth ages 12–18Teen Sobriety & Accountability1 session weekly · $550 / 6-wk moduleParents & caregiversParent De-escalation & Household Rules1 session weekly · $600 / 6-wk module

Preferred Meeting Times

Weekday afternoons (3–5 PM)Weekday evenings (5–8 PM)Saturday mornings

2Referral Source

Who is completing this form? *

Your Name *

Agency / School (if applicable)

Phone or Email *

3Participant Information

For the Teen Sobriety group, list the youth attending. For the Parent group, list the caregiver(s) attending and the youth they are supporting.

Youth Full Name *

Youth Date of Birth *

School / Grade

Town / City *

Parent / Caregiver Name(s) *

Caregiver Phone *

Caregiver Email *

4Reason for Group Referral

Is group participation court, probation, or school required?

Court / ProbationSchoolVoluntary

If required, deadline or completion documentation needed

Current concerns (substance use, conflict at home, rule-breaking, etc.) *

What would you most like to get out of this group?

Current services (individual therapy, in-home, case management)

5Acknowledgment & Consent

I understand that group members agree to keep what is shared in group confidential, and that clinical limits to confidentiality (safety, mandated reporting) still apply.I understand that groups meet once weekly for a 6-week module and that consistent attendance is expected to receive full benefit and any completion documentation.I acknowledge that group services are private pay, billed per module, and I accept financial responsibility for the module fee.I attest that the information in this form is accurate to the best of my knowledge.

Parent / Guardian Signature (Type Full Name) *

Date *

Specialized Group Therapy Referral Form

1Group Selection

2Referral Source

3Participant Information

4Reason for Group Referral

5Acknowledgment & Consent