Girls Teen Depression & Anxiety Support Group Pre-Registration
Please submit this form if you are interested in potentially joining or having your teen (if you are the parent or caregiver) join this support group. After submitting this form, you will be contacted by Sumayyah Rawashdeh (sumayyahrawashdeh@khalilcenter.com) to set up a 1:1 conversation to discuss the details of the support group and any questions or concerns you may have. 

Please keep in mind that this group is limited to girls from the ages of 14-16 and will run weekly on Tuesdays from 6:30-8pm in-person at the Khalil Center office located in MCA (3003 Scott Blvd, Santa Clara, CA 95054) Suite #4 from January 16th to April 2nd 2024. The group will be in a private setting at the office to maintain confidentiality of participants and families. We are aware that Ramadan will be starting around March 10th inshaAllah, and we will adjust the timing as needed according to everyone's schedules when we get closer to that time.

Payment: $30 per session for a total of $120 for 4 sessions (~3 months) paid upfront. Khalil Center will not turn away anyone for lack of funds. 
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Who are you filling this form out for? *
Name  *
If you are filling this form out on behalf of your daughter, please include both your name and your child's name
Email *
Date of birth  *
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DD
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Will you (or your child) be available weekly on Tuesdays 6:30-8pm from January 16th to April 2nd? *
Are you able to commit to 12 sessions and pay the total ($360) fee upfront?
 *
$30 per session for 12 sessions = $360 total
Khalil Center Bay Area does not turn away clients for lack of funds. Payment plans available on an as-needed basis. 
This group space is meant to be confidential and private, meaning that nothing that is shared during the group can be discussed or brought up outside of group sessions in order to ensure every group member is respected in and outside the group space. Do you agree to keep all information discussed during sessions confidential? *
Why are you interested in joining this group? *
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