New Student Form

LIT -Time!!! Registration

Learning Individuality Together Time
Teen’s Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade Level
Mental Health History?
Past Suicidal Ideations

YesNo
Is there anything else you’d like me to know about your teen?
Parent or Guardian

First NameLast Name
Phone Number
Email
example@example.com
There is a 24 hour cancellation policy, so please let me know at least 24 hours before if your child is unable to attend. Space is limited and I cannot guarantee that your child will be able to attend the following group.

I have read and agree to the 24 hour cancellation policy.
I acknowledge that the purpose of this group is to provide support only and no clinical treatment will be provided. I acknowledge that I can contact the facilitator, if I would like more information on therapeutic services and/or other treatment recommendations and referrals.

Yes, I consent to my child participating in this group.No, I do not consent to my child participating in this group.
Parent/Guardian Signature

Clear
*Space is limited*

You will receive an email within 24-48hrs with the zoom link or you will receive notification that your has been placed on the waiting list.

May Meeting Schedule:

Sat, 5/4/2024

Sat, 5/11/2024

Sat, 5/18/2024

Sat, 5/25/2024

3-4PM (EST)

For more information please email:

info@empathiclee.com

THANK YOU!!!
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LIT -Time!!! Registration