Registration form: Rose Wellness Parent Support Group Navigating Emotional Outbursts
Parent Support Group! for parents of children ages 3-8 who have big feelings
Thursdays 12:15-1:30pm in person at our office location : 5266 Hollister Ave

What: Learn from a mental health therapist specializing in this age group but more importantly, get support from other parents who also face similar challenges in parenting little ones with big emotions.  A safe place to share your stories, struggles and successes as well as get resources and ideas from others. Sometimes just being heard can do wonders for our mental health!


USE THIS FORM TO REGISTER FOR OUR PARENT SUPPORT GROUP.

Group: Parent Support Group
When: Thursdays 12:15-1:30pm
Duration: 8 weeks
Where: In person at Rose Wellness (5266 HOLLISTER AVE Suite 238)
Participants: 7 participants max
Facilitator: Julia Cushing, LCSW #108448

Cost: $320 total up front for 8 sessions

(insurance not accepted)

**Payment plan available as follows if desired for $350 total

1st payment -$175 due by first group session

2nd payment- $175 due by week 4 of group

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YOUR NAME *
Your name (person filling out this form)
PRONOUNS *
 What are your pronouns ? (she, he, they, other)
DOB *
Your Date of Birth
MM
/
DD
/
YYYY
PHONE  *
Your phone number
EMAIL *
Your email
ADDRESS *
What is your address? 
CHILD's AGE *
Your child's current age
CHILD'S SCHOOL *
What school does your child  (or children) attend?
What are your biggest challenges as a parent? *
What would you like to get out of this group? *
COST *
Full Cost of the group will be $320 for the 8 weeks.
Would you like to pay in installments for $350 or the full amount up front?
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