Uplift Teen Group Interest Form

Thank you for your interest in NAMI SMC's Uplift Teen Group. 

The Uplift Teen Group is an interactive 6-week support group is designed to help youth (ages 11-18) learn coping skills and improve their overall wellbeing. Each session is one hour long, featuring peer discussions and interactive activities to practice techniques that help change negative thoughts to positive ones.

Please fill out the interest form below so we can be in touch about next steps. If you have any questions, please reach out to our Youth Services Manager, Olivia Heffernan, at olivia@namisanmateo.org. 

__

Next Cohort for 9th-12th Graders:
Starting: Coming in the new year - Please fill out the interest form to be added to our waitlist.

___

Next Cohort for 6th-8th Graders:

Starting: Coming in the new year - Please fill out the interest form to be added to our waitlist.

*all form responses and group sessions are confidential* 

If you are answering the questionnaire for someone else, please fill out the questions to the best of your ability.

For more questions please contact me at (650) 667-1275 or olivia@namisanmateo.org
Sign in to Google to save your progress. Learn more
Name *
Name of Participant (if not self)
Relationship to participant (if not self)
Pronouns *
Sexual Orientation
Clear selection
Gender Identity
Clear selection
Ethnicity/Race
Email *
Email of Participant (if not self)
Age *
Which school do you attend and which grade level? *
What is your home address? Including zip code *
Zipcode *
What interests you about the Uplift Teen Group? *
Which topics/elements of the group are you most interested in exploring?
 *
Required
Have you done any other emotional skills or support groups before? If so, what was your experience like with them? *
Are you currently seeing a therapist or other mental health specialist? *
Do you prefer a virtual or in person group? *
What day(s) of the week are best for you? *
Required
What time(s) on the weekend are best for you? *
Required
What time(s) on the weekdays are best for you?
 *
Required
Emergency Contact Name, Relationship to You, Email Address and Phone Number *
How did you hear about the Uplift Teen Group? *
Do you have any other questions for me?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Nami San Mateo.

Does this form look suspicious? Report

Google Forms