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Group Therapy Registration
When: October 16, 2020 @ 7 PM
What: Join us for our traditional Group Chat but with a twist! Art kits will be provided by Easel Social Canvas and will be mailed to participants. Register by October 8 to receive art kit on time.
Where: Virtual on https://zoom.us/join
Name of Parent/ Legal guardian *
Address (Please put complete address) *
Email *
Phone number/ Alternative Phone Number *
Name of Child *
Gender of Child *
Child's Date of Birth *
MM
/
DD
/
YYYY
Age of Child *
Please describe the loss the youth experienced *
Current School *
Primary language/ other languages spoken *
Required
Waiver for Photos *
Household Income? *
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