Art Therapy Group Intake Round 1
Please respond to the following questions about your child.
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Email *
Student information
Child's Full Name *
Child's preferred name, if applicable
Age *
Date of Birth *
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Sex  *
Grade Currently Enrolled  *
Parent/Guardian #1 Name: *
Email *
Phone number *
Parent/Guardian #2 Name:
Email
Phone number
Emergency Contact Information: (other than parent/guardian(s): Name *
Emergency Contact Information: (other than parent/guardian(s): Relationship *
Emergency Contact Information: (other than parent/guardian(s): Phone Number *
Please list any known allergies: (especially to latex, gluten, and nuts) *
Concerns/Issues: Briefly describe any concerns or issues you would like me to assess and/or address in working with your child *
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