RAGE ROOM ORLANDO AHT 6 WEEK PROGRAM APPLICATION
PLEASE FILL OUT APPLICATION TO THE BEST OF YOUR ABILITY. SUBMITTING THIS APPLICATION DOES NOT GUARANTEE ADMISSION INTO THE PROGRAM. (SAFE ZONE AGES 7-17)
**Registration is not currently open for younger ages . Announcement will be made soon.**
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WHICH PROGRAM ARE YOUR INTERESTED IN *
Required
Parents Name *
First and last name
Email *
Phone number *
 Name of Participant  *
 Age  *
What are the primary challenges or concerns that you (or your child) are currently facing? *
How long have you (or your child) been experiencing these challenges, and what strategies have you tried to address them? *
What are your goals (or your child's goals) in this program? *
Have you or (your child) participated in any form of therapy or counseling before? If so, what was the experience like? *
Are there any specific triggers or situations that exacerbate you or your child’s issues? *
What are your (or your child’s )strengths and interests? *
Is there anything else you think we should know about you (or your child that could help us provide the best support? *
Are you committed to ensuring you (or your child’s) participation in this program if approved, including ensuring attendance and engagement over the full length of the program? *
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