Connect With Creativity Questionnaire

Child's Name*

First NameLast Name

Connect with Creativity, lead by LMHC Judy Ko, is a 10-week experiential arts lab designed to sharpen creative problem solving, facilitate “being in the zone,” regulate stress better and expand imagination through the joy and resilience of artistic expression. Children ages 11–14, with a special interest in visual arts, are welcome to apply!

Sessions are held every other Wednesday from 4-4:50pm PST (7-7:50pm EST). A description of each session is found below.

Part I: Weeks 1–5

Oct 18 - WEEK 1: Embarking: art = play

Nov 1 - WEEK 2: Pattern & Rhythm: a cadence of mark-making

Nov 15 - WEEK 3: Make it Ugly: what does perfect mean anyway?

Nov 29 - WEEK 4: Light & Shadow: and the grays and the colors in between

Dec 13 - WEEK 5: Invisible Things: emotional expression

Part II: Weeks 6–10

Jan 3 - WEEK 6: Cloud of Memories: visualizing what our minds and bodies register

Jan 17 - WEEK 7: Dreams and Things From the Future: imaginings

Jan 31 - WEEK 8: The Prism of Self: our many parts

Feb 14 - WEEK 9: Beauty and Brokenness: a creative process

Feb 28 - WEEK 10: Evolving a Personal Style: listening to yourself

We will engage in variably paced mark-making exercises to activate playful imagination individually and collectively, and also spend time in self-paced free draw, integrating material/technical exploration, learning from each other and being energized by everyone's unique process and style.

Supplies: What you have at home. Suggested materials to have on hand: papers, sketchbooks, pens and pencils, markers, pastels, colored pencils, clay, paint, brushes, etc. Choose what YOU enjoy using!

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 registration.

Caregiver Name*

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Child' Email (if applicable)

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Child's Date of Birth*

Date

What grade is your child in?

Which school does your child attend?

What pronouns does your child use?

Please let us know which sessions you would like to attend.*

Part 1Part 2Both!

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?

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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!