Group Therapy Screening Form

Group Therapy Screening Form
Participant's Name

First NameLast Name
Date of Birth

MonthDayYear
Parent/Guardian's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional Information
Has you child ever shown aggression towards animals or peers?*

YesNo
If yes, please specify:
Does your child have any mobility concerns for which they will need an accommodation?*

YesNo
If yes, please specify:
Do you anticipate/foresee any disruptions or absences for your child?*

YesNo
If yes, please specify:
Does your child exhibit any signs/symptoms of anxiety or depression?*

YesNo
If no, what is your motivation for enrolling your child?:
Does you child have any allergies? Please list below. *
History of individual or group therapy? Has a therapist recommended this group specifically for your child?*
What are your expectations or goals for your child in this group?*
I, the undersigned, acknowledge that this is an unmounted (NOT RIDING) therapy.

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