Middle School Anxiety Skills Group Registration Form
Email *
First & last name of child *
Address *
Best contact phone number *
Date of birth *
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Child's gender identity *
What pronouns does your child use? (e.g. She/Her; They/Them; He/Him; Ze/zir/hir) *
Name of school attending in the fall *
Fall grade level *
Parent/Guardian first & last name(s) *
Parent/Guardian phone #(s) *
Parent/Guardian email(s) *
Emergency contact (Please include name, relationship, & phone number) *
Would you like to mention language, cultural, or identity-based considerations for the Facilitator?
Allergies (please list all or reply 'none') *
Dietary restrictions   *
Does your child have any medical conditions that the group facilitator should be aware of? If yes, please list and describe. *
Is your child on any medications? If yes, please list and describe. *
Does your child have anxiety? *
How does your child do academically? *
Does your child have an I.E.P.? *
How does your child get along with peers? *
Has your child had any special testing or evaluations in school? If yes, please describe.
Does your child participate in any sports, clubs, or extracurricular activities? If yes, please list activities.
Has your child been or is your child currently in counseling? If yes, please provide the name of the therapist.
List your child’s 3 greatest strengths:
List 2 - 3 areas that need improvement for your child:
Briefly describe your child’s interests and/or hobbies:
What are your goals for this group?
Is there anything else you would like us to know about your child to help us in our work together?
Would you like to schedule a parent feedback session to learn more about how your child interacts with and benefits from the group?
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How did you hear about CFCE? *
Would you like to receive email updates (about monthly) from CFCE?
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