Covid 19 Community Support Group for Children

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Please fill out this form with your parents to the best of your ability. This form will be reviewed by a mental health professional and will be utilized for to ensure that this service will provide you with the service that you need. This form is being treated confidentially, and will not be shared. (Please note, confidentiality is broken, as Illinois mandates, in the event that there is any threat of self-harm or harm to others).

Email *

Have you ever, or currently, attended/ing therapy (group or individual)? *

Yes

Do you have a mental health diagnosis? *

Yes

If you answered yes to the previous question, please indicate your diagnosis here:

Are you a resident of Illinois? *

Yes

Have you or someone you know has been treated or currently being treated for Covid 19 (Coronavirus)? *

Yes

If you answered yes to the previous question, please provide a brief description of your experience:

How old are you? *

Please provide a description of your gender: *

Are you attending school? *

Yes

If you answered yes, please provide a brief description of how Covid 19 (coronavirus) has affected your school attendance:

Please provide a brief description of your cultural background (optional):

Are you a current client of TriWellness? *

Yes

Would you be willing to provide feedback after the support group, which will help us determine future group services? *

Yes

Would you like to get more information about the services provided by TriWellness? *

Yes

Una copia delle risposte verrà inviata via email all'indirizzo fornito.

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