East Bay Group Application 2024-2025
Hello! Thank you for filling out our application for groups Fall 2024 - Spring 2025. 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 / Guardian 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 *
Age + Grade as of Sept 2024 (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 may have, or information about your daughter and family that might be useful to us as their guides and as we consider your application. This would include hopes and wishes, challenges, family structure, trauma history, medications, mental health concerns or diagnosis, hospitalization history/concerns, or special needs. *
Is your teen currently seeing a licensed therapist (or have they in the past)? *
Which of the following best represents your daughter's racial or ethnic heritage? Choose all that apply.
How did you hear about us?   *
Thank you! We will get back to you as soon as we've had a chance to review your application.
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