Registration form: LGTBQ Teen Gaming Support Group
This is a support group for LGBTQ Teens ages 14-17 that enjoy the world of gaming!  Sometimes this can be isolating, and hard to find others that you connect.  Having marginalized identities can sometimes increase the amount of isolation that teens feel.   

This group will include weekly virtual meet ups to engage in the world of collaborative gaming (i.e. animal crossing) in order to build connections, talk about identity, gain social skills, and de-stress in the company of other LGBTQ teens and an associate marriage and family therapist.

USE THIS FORM TO REGISTER FOR OUR FALL GROUP.

Group: LGBTQ Teen gaming support group
When: September 18- October 30, Mondays 8-9pm
Duration: 6 weeks
Where: Virtual on ZOOM
Participants: 6 participants max
Facilitators

- Sam Urena Associate Marriage Family Therapist AMFT#131160
Supervised by Rachel Brewer LCSW # #97626

Cost: Groups are $40 per session which is paid up front before the 6 weeks.
Insurance is not accepted

** A few sliding scale spots are available.

Total of 6 weeks. You will get the most benefit out of this group if you attend each week!  If you need to miss 1 or 2 sessions reach out to us ahead of time to chat about whether it's workable or better to wait until the next cycle.
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YOUR NAME *
Your name (person filling out this form)
RELATIONSHIP TO TEEN *
(ex. mother, father, caregiver, grandparent..etc)
PHONE  *
Your phone number
EMAIL *
Your email
TEEN'S NAME *
PRONOUNS *
 (she, he, they, other)
TEEN'S DOB *
MM
/
DD
/
YYYY
SCHOOL *
What School do you go to?
TEEN'S PHONE #
*
What is your teen's phone #
TEEN'S EMAIL ADDRESS *
ADDRESS *
What is your address? 
WHAT IS YOUR TEEN STRUGGLING WITH? *
Required
THERAPY *
Does your teen currently have an individual therapist?
COST *
Full Cost of the group will be $240 for the 6 weeks.
Sliding scale may be available if there is a financial need
Commitment *
Please state if your teen is able to commit to the 6 week cycle, or if there will be any sessions they may need to miss:
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