Mindful Moments Interest Form
A six week therapy group for children 7-11 years old - Please complete this interest form and you will be contacted for further information by our office.
About your child
Please complete the below information about your child (ren)
Child's name
Your answer
Child Age
Your answer
Grade Level
Your answer
Current School
Your answer
Parent Name
Your answer
About the parent
Please complete the information below about the parent responsible for the child
Phone number
Your answer
Email Address
Your answer
How did you learn about this group?
Your answer
Describe your child's previous history with counseling or group counseling?
Your answer
3. What specifically do you hope your child will gain by participating in this group? (select all that apply)
Required
Is there anything else you would like to share about your child?
Your answer
This group will be offered weekly for six consecutive weeks, in the evening from 6 pm - 7 pm. Please select a preferred day for your needs?
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