Together We Are Stronger
Together We Are Stronger
Teen Trauma Therapy Group
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
Date
Participant Grade in School
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide a brief summary about your interest in participating in this group:
Please Select Any of the following symptoms or behaviors that may be present (Select all that apply)
Self Harm
Suicidal Ideation
Sleep Disruptions
Anxiety
Depression
Nightmares
Enuresis/ Encopresis
Peer Issues
Inattentivity
Mood Dysregulation
None of the Above
Other___________________________
What are you hoping to accomplish from this group
Name of Insurance Coverage
Please Select
Blue Cross Blue Shields
Blue Care Network
Meridian Medicaid
McLaren Medicaid
Blue Cross Complete
Insurance # and Group #
Submit
Should be Empty: