Fresh Start Counseling

Group Counseling — Apply

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You're applying to

Real Talk

Led by Edison Jaquez, LAC

Black men, 18+ Schedule TBD — contact us to learn more

Apply to join this group

A few quick details so we can pre-screen and call you back within 1 business day.

1 Who is seeking the group?

Myself

I'm joining the group

Family Member

Applying for someone else

2 Your information (Parent/Guardian)

You're filling this out — we'll collect the participant's info next.

First Name

Last Name

Phone

Relationship

2 Your information

First Name *

Last Name *

Email *

Phone *

Date of Birth

Address (optional)

3 Payment information

Do you have insurance? *

Yes

I'd like to use my insurance

Self-pay / out-of-pocket

Self-pay selected. Our team will discuss rates and options when we call you.

Insurance Provider *

Member ID

Group Number

Snap photos of both sides of your insurance card. Helps us verify your coverage before the first session.

Insurance Card — Front

Insurance Card — Back

Flex/HSA Card (optional)

If you have an FSA or HSA card, upload it for copays.

5 When are you generally available?

Pick any that apply — we'll match you to the cohort time when we call.

Weekday mornings

Weekday afternoons

Weekday evenings

Saturdays

Sundays

I'm flexible

Text me reminders. By checking this you agree to receive SMS messages from Fresh Start Counseling about your group cohort. Message + data rates may apply. Reply STOP to opt out anytime. See our SMS terms.

We respond within 1 business day. Questions in the meantime? (609) 503-0484