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Teen LGBTQ+ Group
Ages 13-18
Thursdays at 6:30 pm
Open attendance (maximum of 8 per session)
Contact
groups@embark-counseling.com
with any questions.
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Email
*
Your email
Teen's Name
*
If you are registering more than one teen, please complete an additional registration form.
Your answer
All Parent's/Guardian's Name and Phone Numbers
*
Your answer
Address
*
Your answer
Teen's Date of Birth
*
Your answer
Does your teen have any allergies?
*
Your answer
Does your teen have any concerns with safety or any special accommodations requests?
*
Your answer
Is your teen currently seeing a counselor/therapist?
*
Yes
No
If you answered yes, please provide your counselor/therapist's contact information below.
Your answer
Form of Payment (billed at each session)
*
Credit Card (CC authorization on file - $40.00 per session)
Check (made payable to Embark Counseling Services - $40.00 per session)
Insurance (email
info@embark-counseling.com
to see if your insurance covers this group)
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