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Online Skills Group Registration Form
with Dr. Andrea Stelnicki (High Point Psychology)
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* Indicates required question
Child's Name (First & Last)
*
Your answer
Child's Birthdate
*
MM
/
DD
/
YYYY
Child's Grade
*
Your answer
Child's Address
*
Your answer
Parent Name (First & Last)
*
Your answer
Parent Email Address
*
Your answer
Parent Phone Number
*
Your answer
Parent Address (if different from child's)
*
Your answer
Is consent required from both parents because you are separated/divorced and share consent/decision-making authority?
*
Yes
No
If yes, please provide second parent's contact information (name, email address, phone number, home address).
Your answer
How did you hear about this group?
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High Point Psychology website
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