Weekly Group Interest Form

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We are offering a 1.5 hour weekly group program for kids with anxiety disorders.

The program starts on April 7th. Program hours are 9:30-11am.

The cost of the program is $1,200 for 6-weeks.

Sessions will include social skills training, arts and crafts activities and interactive play.

**A screening process will be required for any new clients**

Child's First Name *

Child's Last Name *

Child's Age *

Name of the person filling out this form *

What is your relationship to the child? *

Parent/Guardian

Grandparent

Teacher

Therapist/Psychologist

Other school professional

Other:

What is the best phone number to reach you? *

What is your e-mail address? *

Does your child have any established diagnosis(es)? If so please indicate. *

Is your child currently in therapy or being treated by a mental health professional? *

Yes

Not currently, but he/she has in the past.

Not currently, but I am looking for a provider and am open to regular therapy.

What skills would you like your child to gain and/or why do you think your child would benefit from this program? *

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