12-Week Youth Emotional Regulation

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Tuesdays | 5:00-6:00pm | April 4th -June 20th | Ages: 11-14

Please complete this form to register for the Youth Emotional Regulation. Once this form is completed and receive, you will receive an email welcoming you to our online Portal to complete the paperwork necessary to schedule your intake session. All Groups require a one-hour intake (separate fee).

Youth First & Last Name *

Youth Date of Birth *

YYYY

Parent First & Last Name *

Parent Phone Number *

Parent Email Address *

By completing this registration form you are agreeing to be contacted by one of our clinicians to schedule an intake session. *

Yes

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