Divorce Care Group for students
Please complete form to be considered for our group. Students ages 7 -12 for teens.
Email address
Name of Parent(s)
Your answer
Best phone to reach you
Your answer
Name of Child and Date of Birth
Your answer
Where does the child currently attend school?
Your answer
Has the child had any academic or behavioral problems in school?
If yes, check all that apply:
Are behavioral problems present in situations other than school (Home/Other places)?
If yes, check all that apply:
Does the child have any medical problems?
If yes, please describe...
Your answer
Is the child under the care of a mental health professional?
If yes, please provide the professional's information...
Your answer
Has the child been diagnosed with any learning disabilities?
If yes, please describe...
Your answer
Does the child have any history of depression, anxiety or other similar problems?
If yes, please describe...
Your answer
Is there a history of abuse (sexual, physical, etc.) towards the child?
If yes, please describe...
Your answer
Who is responsible for bringing the child to group?
Please complete the captcha before submitting the form.
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