Sister Circle: Teen Edition (Information Form)

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Thank you for your interest in the Sister Circle: Teen Edition, support group.

We are so excited to offer this FREE 3-week support group for teen girls.

This support group will offer a safe space for your teen to speak their mind, and a community to listen and support them.

The group will take place March 11th, March 18th, and March 25th from 5-6:15pm

VIRTUALLY via Zoom.

Please complete this form in its entirety, please submit one form per child.

If you have any questions, please reach out to us via phone or email. All contact information is below.

You will receive more correspondence from us a few days before the group begins on March 11th.

We appreciate your interest!

Take care

Email: info@simscounseling.org

Phone: 502-936-6546

Website: www.simscounseling.org

Child's Name (First and Last) *

Child's Date of Birth *

YYYY

Child's School *

Parent's/Guardian's Name (First and Last) *

Parent's/Guardian's Mobile Number *

Parent's/Guardian's Email Address *

Preferred Method of Contact *

Phone

Text

Home Address (Address, City, State, Zip Code) *

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Has your child experienced any self-harm/suicidal ideation or attempts within the last 6 months? *

Yes

If the previous answer is "yes", please provide a date of said occurrence: *

YYYY

Please express your general interest in group for your teen? Feel free to add any additional information you would like for us to know. *

Are you interested in your child receiving individual therapy at Sims at this time? If so, our admin will reach out to you to discuss mental health options.

Yes

Maybe, tell me more

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