2026 Teen Anger Management Group Form

Teen Anger Management Group

Contact and Basic Information
Thank you for your interest in Greenleaf's Teen Anger Management Group.

The first session is Monday, May 4, 5 p.m. at Greenleaf Family Center. Participants can join the group at any time and continue their 12 weeks until completed. Each group is limited to eight members.

By filling out the below form, you are by letting us know that you and your teen are interested in the program and would like to move forward with an assessment to see if the group is right for your family and that your teen will benefit from participating.

Once you've submitted the form, one of Greenleaf's intake specialists will contact you about scheduling your assessment. In the meantime, if you have any questions, please call 330-376-9494 ext. 209.

Thank you!
Today's date*

MonthDayYear
Date
Contact Information

Parent/Guardian/Caregiver/Legal Representative
Legal Name (Parent, Guardian or Caregiver)*

First NameLast Name
Home/Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your nickname or preferred name, if applicable?*
Pronouns*

She/HerHe/HisThey/ThemPrefer not to answer
Do you have permission to speak on behalf of the below participant(s) and make appointments for them? Do you have paperwork that you will be able to supply prior to their first group session via email or fax?*

YesNo
Contact Information

Minor Participant (13-17 years old)
Legal name*

First NameLast Name
Home/Permanent Address (skip if same as primary contact)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (skip if same as primary contact)
example@example.com
Phone Number (skip if same as primary contact)
Please enter a valid phone number.Format: (000) 000-0000.
Age *
Date of Birth*

MonthDayYear
Date
Gender*

BoyGirlNon-binaryOtherPrefer not to answer
If the answer is Other and they would like us to know how they identify, please use this space to tell us.
Nickname or preferred name, if they have one?*
Pronouns*

She/HerHe/HisThey/ThemPrefer not to answer
How did you hear about Greenleaf and our Behavioral Health Programs? (choose all that apply)*

Word of mouthReferral from a friend or family memberAttended a Greenleaf eventFacebook adFacebook or Instagram feedInternet search/websiteCourt-mandatedAgency referral
If you were referred to Greenleaf by another agency or organization, please let us know which one and who you are working with so we can connect back with them.
If you attended a Greenleaf event, which one and when?
Thank you for contacting Greenleaf!
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Teen Anger Management Group

Contact Information

Contact Information