ARTS Groups
This is a screening tool for the 7 week group focusing on skill building in the areas of Awareness, Acceptance, Resilience, Reconnection, Transitions, Tools and Self-Esteem. Please respond to all questions. If you would like to elaborate on any question, please use space at the end of the form labeled "Any additional information you would like the group therapist to know".
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Email *
Phone Number *
Client Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
School of Attendance *
Grade *
Parent's Names *
Parent's relationship status *
If parents are divorced, what is current custody arrangement?
Siblings? If so, please include ages *
Why are you interested in your child attending this group and what are you hoping they gain from it? *
Primary Concerns: *
Required
Has your child experienced suicidal thoughts and/or attempted suicide? *
Has your child experienced homicidal thoughts? *
Is your child engaging in self-injurious behaviors? *
Have there been major family stressors? *
Required
Has your child experienced, witnessed, or reported any traumatic event in their lifetime? *
Has your child received any significant prior medical or mental health diagnosis? *
Is your child currently prescribed medication for mental health purposes? *
Required
Any additional information you would like the group therapist to know:
Submit
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