MFY Teen and Young Adult
We encourage families to fill out this form together. Any information is confidential.   No answer provided will exclude a teen from the program. We are would like to know the various dynamics in the group to better serve the needs of our clients.
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Email *
Parent / Guardian Name *
Parent / Guardian Phone number *
Teen name *
Teen Age *
What course are you taking? *
Teen Cell Phone or Email for Weekly Home Practice *
What is your primary reason for your child taking the course? *
What would you like your adolescent to get out of the  mindful self compassion training?
Has your child been hospitalized for or diagnosed with any mental health related condition in the past year such as anxiety or depression (Note that this does not necessarily preclude your child from participating in the course)? If so, when was this? *
Is your child currently under the care of a therapist? If so, may we contact him/her if we feel that it is warranted? If yes- Please provide contact info for therapist
Is there anything else that you would like us to know about your child?
Teens are considered minors until the age of 18, facilitators are required to report threats to personal safety, including clients’ threats or intentions to harm themselves or others. Most important for the success of the course is the confidential and trusting relationship created between the teen and facilitator. In order for your teenager to trust the facilitators, he or she must know that they will keep what he or she shares in confidence. In general, you shouldn’t expect facilitators to share anything other than general information about whether or not your teenager is making progress. The only exceptions being the disclosures of abuse or threats to personal safety as discussed above. *
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