ADHD Group Interest

Complete this form to request enrolling your child in the ADHD Support Group.

After you submit, Hannah will begin to help you determine if this group is the best fit for your child. She will respond to you via email within 48 hours.

The overall purpose of the group is to teach ADHD boys in the 6th and 7th Grades to work with their brains rather than against them.

Parent Name

First NameLast Name

Relationship to Youth

Parent Email - This is the email we will use to contact you. Please provide an email that you regularly check. If you don't hear from us, be sure to check your Spam or Junk folders.

Confirmation Emailexample@example.com

Phone Number for Appointment Confirmation Text(s)

Youth Name

First NameLast Name

Child's current age

This group is for ADHD boys in 6th and 7th grade. The goal is to help teach ADHDers about their brains and to help them develop strategies to navigate common ADHD experiences such as emotional dysregulation, struggles with executive functioning, and navigating social environments. This group would be most helpful for kids who have a little bit of knowledge regarding ADHD and are ready to build these skills in a group setting. Does this group sound like a good fit for your child?

Hannah will give you a call after she receives this form. Together we can decide if this seems like a good fit for your child.

Has this youth ever been evaluated or diagnosed (relating to your concerns about their attention/hyperactivity)?

Tell us a bit about that evaluation/diagnosis:

Briefly describe the challenges you hope this group will relieve/resolve for your child/family:

Referral Name: If you were referred by someone (e.g. School Counselor), please provide their name and the name of their organization (e.g. name of school).

Referral NameReferral Organization

Please provide any additional information you would like to share with us:

Consent: Before providing services to a minor, we must ensure that the correct adults have provided consent. Sometimes,this is the birth parents. Sometimes the right to consent has been changed or assigned by a divorce decree, custody agreement, adoption decree, letter of guardianship, other court order, or some other legal document.

Has this child ever been named in a document that designated which adults can provide consent?

Texas law requires the therapist to have a copy (physical or electronic)of this legal document. Do you have a copy you can bring to your intake?

Texas law requires the therapist to have a copy of this legal document. We will not be able to schedule your intake at this time, but we will provide you with an email to contact when you have that document in hand.

Great! Please bring it to your intake session or email it to your therapist in advance. Texas law requires us to have a copy and we cannot meet with you until we have it. Thanks.

Request for Services