KIDZ THERAPY KITZ ORDER FORM
Kids Mental Health Matter
PARENT/GUARDIAN's Name
First Name
Last Name
CHILD's Name (1)
First Name
Last Name
Child (1) Gender
Please Select
Male
Female
Gender Neutral
Non-Binary
Child (1) Age
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
Child (1) Race/Ethnicity
Please Select
African American/Black
Caucasian/White
Latino/Hispanic
Asian
Native American
Pacific Islanders
Alaska Natives
Arabs
Indigenous People
Indian
Mixed
Bi-Racial
Afrianers
Hawaiians
French
Russian
Haitian
Jamaican
Irish
Jewish
Turkish
Italian
CHILD's Name (2)
First Name
Last Name
Child (2) Gender
Please Select
Male
Female
Gender Neutral
Non-Binary
Child (1) Age
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
Child (2) Race/Ethnicity
Please Select
African American/Black
Caucasian/White
Latino/Hispanic
Asian
Native American
Pacific Islanders
Alaska Natives
Arabs
Indigenous People
Indian
Mixed
Bi-Racial
Afrianers
Hawaiians
French
Russian
Haitian
Jamaican
Irish
Jewish
Turkish
Italian
CHILD's Name (3)
First Name
Last Name
Child (3) Gender
Please Select
Male
Female
Gender Neutral
Non-Binary
Child (3) Age
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
Child (3) Race/Ethnicity
Please Select
African American/Black
Caucasian/White
Latino/Hispanic
Asian
Native American
Pacific Islanders
Alaska Natives
Arabs
Indigenous People
Indian
Mixed
Bi-Racial
Afrianers
Hawaiians
French
Russian
Haitian
Jamaican
Irish
Jewish
Turkish
Italian
CHILD's Name (4)
First Name
Last Name
Child (4) Gender
Please Select
Male
Female
Gender Neutral
Non-Binary
Child (4) Age
Please Select
4
5
6
7
8
9
10
11
12
13
14
15
16
Child (4) Race/Ethnicity
Please Select
African American/Black
Caucasian/White
Latino/Hispanic
Asian
Native American
Pacific Islanders
Alaska Natives
Arabs
Indigenous People
Indian
Mixed
Bi-Racial
Afrianers
Hawaiians
French
Russian
Haitian
Jamaican
Irish
Jewish
Turkish
Italian
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT Email
example@example.com
PARENT Phone Number
Please enter a valid phone number.
My Products
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Therapy Kit (Regular Box)
Includes journal, fidgets for anxiety, stress balls, book, therapeutic resources, list of 52 weeks of mental health activities and lessons & more. FOR AGES 5 - 9. Please allow 10 - 12 business days for delivery.
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Therapy Kit w/ 52 week lessons
Includes journal, 52 lessons on mental health related issues, fidgets for anxiety, stress balls, book, therapeutic resources, list of 52 weeks of mental health activities and lessons & more. FOR AGES 10 - 15. Please allow 10 - 12 business days for delivery.
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
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