Empowerment Group Form

Youth Counseling Connection is a non-profit agency that has been providing quality services to children and families for over 10 years.  Our small group activities are developed to improve academic success, build healthy relationship skills, and support the healthy development of each child we serve.  Our services are voluntary and there is no cost to you or your child for these services.  Please take a moment to complete the registration form below. If you have any questions or concerns, please contact us at 781-862-0330. We will be reaching out once the form is received to explain next steps! 

Referral Name (if applicable):
Referral Relationship (if applicable):
Parent/Guardian Name: *
Parent/Guardian Email *
Parent/Guardian Address *
Parent/Guardian Phone number *
Youth Name *
Youth Birthday
Youth School/Grade:
What do you hope your youth gains from our empowerment group?
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