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Mindful Teen Group Registration Form
* Indicates required question
Email
*
Your email
First & last name of Teen
*
Your answer
Home Address
Your answer
Best contact phone number
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Teen's gender identity
*
Female
Male
Transgender
Non-Binary
Gender Fluid
Non-Conforming
Prefer not to say
Other:
What pronouns does your Teen use? (e.g She/Her; They/Them; He/Him; Ze/zir/hir)
*
Your answer
Name of school attending (Fall 2022)
*
Your answer
Grade in the fall
*
Your answer
Parent/Guardian first & last name(s)
*
Your answer
Parent/Guardian phone #(s)
*
Your answer
Parent/Guardian email(s)
*
Your answer
Emergency contact (Please include name, relationship, & phone number)
*
Your answer
Would you like to mention language, cultural, or identity-based considerations for the Facilitator?
Your answer
Allergies (please list all or reply 'none')
*
Your answer
Dietary restrictions
*
Vegetarian
Vegan
Kosher
Halal
Gluten-free
None
Other:
Does your Teen have any medical conditions that the group facilitator should be aware of? If yes, please list and describe.
*
Your answer
Is your Teen on any medications? If yes, please list and describe.
*
Your answer
Does your Teen have anxiety?
*
None
Mild anxiety
Moderate anxiety
Severe anxiety
How does your Teen do academically?
*
Below average
Average
Above average
Does your Teen have an I.E.P.?
*
Yes
No
How does your Teen get along with peers?
*
Below average
Average
Above average
Has your Teen had any special testing or evaluations in school? If yes, please describe.
Your answer
Does your Teen participate in any sports, clubs, or extracurricular activities? If yes, please list activities.
Your answer
Has your Teen been or is your child currently in counseling? If yes, please provide the name of the therapist.
Your answer
List your Teen’s 3 greatest strengths:
Your answer
List 3 areas that need improvement for your Teen:
Your answer
Briefly describe your Teen's interests and/or hobbies:
Your answer
What are your goals for this group?
Your answer
Is there anything else you would like us to know about your Teen to help us in our work together?
Your answer
Would you like to schedule a parent feedback session to learn more about how your Teen interacts with and benefits from the group?
Yes
No
Maybe
Clear selection
How did you hear about CFCE?
*
Your answer
Would you like to receive email updates (about monthly) from CFCE?
Yes
No
Clear selection
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