Brave Minds Interest Form
Teen's Name
*
First Name
Last Name
Teen's Age/Grade
*
Parent/Guardian Name(s)
*
First Name
Last Name
Email
*
example@example.com
Parent 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
Back
Next
What concerns are you hoping this program will address?
*
OCD (e.g., checking, contamination, "just right")
Panic or physical anxiety symptoms
Social anxiety
Specific phobia
General anxiety/excessive worry
Other
Has your teen participated in therapy before?
*
Yes (ERP specifically)
Yes (other therapy)
No
Submit
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