2025 DLC Group Registration Form

Student Name

Birthdate

Date

Grade

School

ParentGuardian

Phone #

Preference: Circle one Call /Text/Email

Circle one Call TextEmail

example@example.com

Group sessions $35 per session

Select one: [ ]Cash pay/ [ ]Insurance

Insurance Member Id

Grp

Reason for referral: Check all that apply:

Anger Management Bullying Adjustment Anxiety

Homelessness/Transient living Depression Negative attitude/Defiant Withdrawn/Shy/Self-esteem Personal hygiene

Other

Comments

4613 Parkway Drive, Suite 5

Texarkana, AR 71854

870-587-7021 * 870-275-4860 fax www.dreamlabcounseling.net

I consent to my student participating in the process group at DreamLab Counseling Everything shared in sessions and the written notes are confidential and may not be released to anyone without written permission except where disclosure is required by law I understand and give my informed consent for my childs participation

, participating in the process group at

DreamLab Counseling. Everything shared in sessions and the written notes are confidential and may not be released to anyone without written permission, except where disclosure is required by law. I understand and give my informed consent for my child's participation.

ParentGuardian Signature

ParentGuardian Name print

Date

"Helping students see the Dream inside become reality."

4613 Parkway Drive, Suite 5

Texarkana, AR 71854

870-587-7021 * 870-275-4860 fax www.dreamlabcounseling.net