Registration form: TeenWell
This is a therapy group focused on helping teens learn how to manage stress, regulate emotions, and improve relationships.

USE THIS FORM TO REGISTER FOR OUR SPRING GROUP.

Group: TeenWell Spring Cycle (Incoming 9th-12th graders)
When: April 1st- June 3rd 2024 , Mondays 4-5pm- Skip May 27 Memorial Day
Where: In person 5266 Hollister Ave, Building B, Suite 238
Participants: 7 participants grades 9-12
Facilitators
  • Leilani Nguyen- Registered Associate Marriage Family Therapist #135379, 
  • Emily Jacobs Registered Associate Marriage Family Therapist #132880
    Both supervised by Julia Cushing LCSW #108448.
Cost: This group is FREE due to sponsorship by Youthwell ( or covered by your insurance). If not covered by insurance, Suggested donation is $25 per group.

Total of 8 sessions.  We require all of our teens to make an effort to attend all 8 sessions on Mondays.  If your teen cannot commit to this, we encourage you to wait until the next cycle.  We require this so that we can ensure that a safe and understanding space is created in the group so that each teen can benefit.  
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CAREGIVER NAME *
Your name (person filling out this form)
RELATIONSHIP *
Your relationship to participant/student
PHONE  *
Your phone number (person filling out this form)
EMAIL *
Caregiver email
Do you have full legal custody (either married with teen's other parent, or awarded full custody if separated?) *
TEEN/STUDENT INFORMATION
Teen's Name *
Name of the participant
Participant's name they go by
 (if different than above)
Participant's pronouns  *
 (she, he, they, other)
School *
Participant's school
Participant's Date of Birth *
MM
/
DD
/
YYYY
Teen Phone
 *
What is the participant's phone number?
Teen Email *
Address *
Address of the participant
Grade *
Participant's grade
# Children *
How many children are in your family?
Challenges my teen is currently having *
Required
Therapy *
Does the participant currently have individual therapy?
INSURANCE & FEES
Insurance *
What type of insurance does the participant have? We will check benefits and see if group therapy is covered under their plan. Type N/A if teen is not currently insured  
Note* you do not have to have insurance to participate (groups are free)
Teen's insurance member ID  *
( type N/A if no insurance)
Primary subscriber  *
Primary subscriber of the insurance plan (first and last name and DOB) 
Type N/A if no insurance.
Donation *
If your insurance doesn't cover group therapy, group will be free
with a suggested donation of $25 per week (for each meeting).  
Let us know if you are able to make a donation to help support the group.  
Commitment *
My teen can commit to at least 6 out of 8 of the group meetings
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