Store Register Today! Please complete the form below to purchase any of our Services or products. Client Name* First Last Client Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client Phone*Client Email* Referral Source NameIf you are referring someone to our program, please list your name here: Referral Source Phone NumberIf you are referring someone to our program, please list your phone number here: Referral Source EmailIf you are referring someone to our program, please list your email here: Coaching Agreement*I understand that Anger Management is a psychoeducational service. Anger management education is not psychotherapy or counseling. If I need a referral for counseling or am experiencing any mental health concerns, I will seek support through a psychotherapist. I agree Service Agreement*I understand that this purchase is non-refundable. I agree to all terms and conditions of this purchase. I understand that missed appointments are non-refundable. If you need to change your appointment, it must be rescheduled at least 24 hours prior to your original appointment. I agree Contact Agreement*I agree that it is okay for Anger Management U to contact me, or the individual I have referred, at the phone number and/or email listed above. Once you submit payment you will receive an email or call from an Anger Management U representative (within 48hrs) with details of the program or to schedule an appointment. I agree Please select a service:*Online Individual Session: 45 Min. ($150)Online Group Video Session, 8 Weeks: 75 Min ($150 for required 1:1 intake + $75/week for the group)Private 1:1 Session: Stony Brook, NY ($150)Group Program in Stony Brook, NY 8 weeks ($150 for required 1:1 intake + $75/week for the group)One Day Workshop in Stony Brook, NY ($195)Total $0.00 Δ