Finding Myself (Teens Virtual Support Group) Questionnaire

The Finding Myself (Teens Virtual Support Group) lead by our newest team member Adora Du is for teens ages 14-18. It's a virtual support group for teens who are seeking connection and skills in establishing a sense of self and their desires for the future. Each week will cover a different theme in life and how that ties into the concept of identity (for example, family, friendships, self-esteem, achievement, and navigating uncertainty). Each session will provide space for group members to share their own experiences on the weekly topic, and psychoeducation will be provided related to each week's topic.

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

To apply, 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?

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?

How did you hear about this group?

Other

The group meets online on Tuesdays from 4:00pm-5:00pm on the following days:

Nov 7th
Nov 14th
Nov 21st
Nov 28th
Dec 5th

The group is a prepaid service. 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!