SPACE Interest Form
Please complete the interest form below. Once submitted, our Community Mental Health Liaison Anna MacDonald, LMSW, will reach out to complete a more in-depth screening to determine your eligibility for the group. Please note that completing this form does NOT confirm your enrollment into the group.
Parent Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Name
*
First Name
Last Name
Child Pronouns
*
Child DOB
*
-
Month
-
Day
Year
Date
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Does your child struggle with...
*
Generalized Anxiety
Social Anxiety
Separation Anxiety
Obsessive Compulsive Disorder
Other
Describe the nature of their anxiety.
*
Do you find your child's anxiety impacts their siblings/ family dynamics?
*
Yes
No
In the past 2 weeks did you engage in any of the following behaviors in response to your child's fear or anxiety?
*
Responded on behalf of my child to someone speaking to them
Let my child sleep in parents' bed, despite parents' wishes
Let my child skip a social or extracurricular activity that they had committed to
Let my child stay home from school
Drove my child to/from school, despite planning for them to take the bus
None
Other
Please describe any other situations where you find yourself making accommodations for their anxiety:
*
Are there other mental health concerns/diagnoses? Please add any other relevant information here:
*
Are you interested in...
Group Treatment
Individual Treatment
Unsure
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How did you learn about SPACE?
*
Submit
Should be Empty: