East Bay Group Application 2026-2027
Hello! Thank you for filling out our application for groups Fall 2026 - Spring 2027. All information below will remain confidential. Your contact information will only be used to create a group email for parents & guardians. Youth information will only be used to create a group text, upon permission at the start of the group. Thank you. We look forward to sharing this powerful journey with your family :)
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Parent(s) / Guardian(s) Name *
Parent(s) Occupation*
Email *
Phone Number *
Address *
Participant's Name *
Participant's Email
Participant's Phone Number (if they have one)
Participant's School *
Participant's Birthday *
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Age + Grade as of Sept 2026 (this will help us sort what group is the best fit for your daughter.) *
Yes, I understand the program, and our intention is to participate in all that we can. (Full details on website) * *
Payment Method *
Please share any questions you have, or any information about your child or family that would be helpful for us to know as we consider your application and support your teen's experience in the group. This may include your hopes and wishes for your teen, challenges they are navigating, relevant trauma or life experiences, medications, mental health concerns or diagnoses, hospitalization history and concerns, or accommodations/support needs. 
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Are there any aspects of your teen's or your family's identities or cultures you'd like us to know about to better support your teen's experience in the group? This may or may not include racial, ethnic, or cultural identities, socioeconomic background, LGBTQIA+ identities, disability and/or neurodivergence, family structure, or religion/spirituality. 

Is your teen currently seeing a licensed therapist (or have they in the past)? *

Does your teen have access to their own phone or digital device?

What kind of device is it?

What social media or online platforms (if any) do they use that you know of?

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How did you hear about us?   *
Required
* * * PLEASE CLICK THE SUBMIT BUTTON BELOW * * *
Thank you! We will get back to you as soon as we've had a chance to review your application.
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