Art Together Questionnaire WAITLIST

Art Together group is a hybrid virtual and in-person environment for ages 10+ to practice creating healthy friendships while engaging with arts and crafts. Each session is guided by a child therapist and a graduate level clinical intern.

Over the course of 7 weeks, Art Together will be a creative expression group with a focus on building strong, supportive friendships. Our goal is to provide a safe and supportive space for participants to express themselves creatively and build meaningful connections with others who share their interests. Through engaging in a variety of art projects and activities, participants can explore different forms of creativity and personal expression.

This is not considered a healthcare service, and is therefore NOT billable to insurance.

To apply to the waitlist, please fill out the form below. We will review your form to ensure your child will be a good fit for the group. Once approved we will send you a welcome letter, consent form to sign, and an invoice to finalize your registration. THIS FORM DOES NOT FINALIZE YOUR REGISTRATION!

Child's Name*

First NameLast Name

Caregiver Name*

First NameLast Name

Relationship to Child*

Caregiver Contact Email*

example@example.com

Child' Email (if applicable)

Caregiver Phone Number

Please enter a valid phone number.

Child's Date of Birth*

Date

What grade is your child in?

Which school does your child attend?

What pronouns does your child use?

What special interests does your child have?

Does your child have access to...

	Yes	No
A computer
A quiet space
Internet

Do you have any social, emotional or behavioral concerns for your child? If so, what are they? (Example: "my child sometimes struggles to communicate when they are frustrated")

Why are you seeking group support for your child?

What are you hoping your child gains from being involved in this group experience?

Next session dates are TBD. We will contact you when with the session dates are available. If they do not work with your schedule, we will keep you on the waitlist for future sessions.

The group is prepaid, if you are ill or not able to attend one of the groups, we unfortunately, will not be able to provide any refund.

Is there anything else you would like us to know?

Thank you filling out the screening form. Once you submit the form, we will review your form to ensure your child will be a good fit for the group. Once approved we will send you a welcome letter, consent form to sign, and an invoice to finalize your registration.

THIS FORM DOES NOT FINALIZE YOUR REGISTRATION!