TEEN SUPPORT GROUP INTEREST Form

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TEEN SUPPORT GROUP INTEREST Form

Helpful Therapy Center LLC

This form is intended to document the interest of potential teen participants in group therapy sessions. These sessions will be offered on Saturdays twice a month. Teens aged 13-15 are offered sessions from 11-12:30pm and teens 16-18 can attend from 1-2:30pm. SEE OUR WEBSITE FOR MORE INFO

Please provide your name (include pronunciation if possible). *

Please provide your teen's name (include pronunciation if possible). *

Please provide your phone number. *

Please provide your email. *

Please provide your address. *

Relationship to the teen. *

Mother

Father

Legal Guardian

Does your teen currently experience any of these challenges? (Please select all that you believe apply) *

Depression, depressed/low mood

Anxiety

Challenges understanding their mental health

In need of a peer/age-based outlet

In need of a support system

Drastic or noticeable changes in grades

Other:

Required

How old is the teen? *

13-15

16-18

How does the teen identify? *

Female

Male

Transgender

Nonbinary/Gender nonconforming

Other:

Has the teen previously been in therapy? (If yes, use "other" to notate when and for what reason) *

Yes

Other:

Will the teen be able to attend all 10 sessions (2 missed session are allowed)? *

Yes

Please provide any additional information you believe will be useful when determining if this is the best fit for your teen.

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