Queer Youth Therapy Group

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This is our therapy request form for local queer and questioning 13 to 18 year olds interested in our hybrid therapy program. This group involves a combination of group therapy and individual therapy. Youth are welcome to register themselves, or an adult may fill this out on their behalf.

Please know we will reach out to the contact information provided below and we will leave voicemails/emails with our agency name and that we are responding to your referral. If you need an accommodation due to privacy concerns, please note so in the "Notes" section at the bottom of the form.

Name used by prospective client: *

Client Pronouns (optional)

Client birthdate *

Best email to send meeting notices and related information to: *

Residential Address (including city) *

Best contact phone number for a client intake phone call: *

This inquiry is for: *

Yourself!

A youth you work with

A youth you are the parent/guardian of

Other:

Does the youth client identify as LGBTQ, Two-Spirit, and/or Queer, or are they questioning their gender identity and/or gender orientation? *

Yes

Other:

If someone other than the client is filling out this form, please include below your name and contact information, along with your relationship with the youth.

Notes: Is there anything else you would like us to know before contacting you? *

Thank you for your interest. We will reach out to your contact information in the next few weeks.

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