A Group For Girls
TREAT your Mind Kind.Thrive in this 8-week group for girls.Being mindful when listening and participating; interacting with one another in a polite and respectful manner; gaining confidence in the group setting; understanding of the lessons and vocalize that understanding. .
Start/End Dates: March 11 - April 29th
Start and End Times: 4:00-5:00 (10-12), 5:00-6:00 (13-15). Every week, two hours for age group 10-12. Every week, one hour for age group 13-15
Name of parent or guardian
First Name
Last Name
Participant's Name
First Name
Last Name
Participant's Date of Birth
-
Month
-
Day
Year
Date
What age group and time are you signing up for?
Ages 10-12: 4:00 - 5:00 p.m.
Ages 13-15: 5:00 p.m. - 6:00 p.m.
Is participant currently a WSCC client
Yes
No
If yes, who is the participant's current clinician?
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance?
Private
Medicaid
None
None, but interested in learning about sliding scale program
If you have insurance, please provide carrier name, group and/or ID number
How did you hear about this group?
Social Media (Facebook, Instagram, LinkedIn, Twitter)
Enewsletter/Eblast from WSCC
Word of Mouth
Online Ad
WSSC Counselor
Other
Questions/Comments
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