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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