Supportive Parenting for Anxious Childhood Emotions (SPACE) Parent Group Intake Form
Whether your child is struggling with social fears, separation anxiety, or constant worry, you will walk away with a better understanding of how to support and communicate with your child, and have the tools and resources you need to help break the cycle of anxiety. 

This program is available virtually in all PsyPact States
Includes all materials for 2 caregivers

Next Session Date TBD - fill out your intake now to get priority registration!
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Email *
Phone Number: *
Child's Name:
How old is your child? 
Parent(s) Name(s):
What are your main concerns regarding your child? 
Has your child been diagnosed with any of the following:
If you selected one or more diagnoses above, at what age was your child diagnosed and by whom?
How have your child's symptoms impacted your life at home, work/school, and/or socially?
Has your child received or is currently in treatment for anxiety and/or OCD?
Clear selection
If yes, who is/was their treatment provider?
How did you hear about this SPACE Parent Group? Did anyone refer you to our clinic? *
What are you hoping to achieve through the SPACE group?
Submit
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