MSC-T Expression of Interest
We encourage families to fill out this form together. All information is confidential. No response will necessarily exclude a teen from participating; rather if we have questions as to whether the program is appropriate for the teen, we will contact you. We would like to know the various dynamics in the group to better serve the needs of our clients.
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Full Name Of Participant (Please include preferred name if relevant) *
Participant Email *
Parent/Caregiver Full Name *
Parent/Caregiver Email *
Parent/Caregiver Phone Number *
Teen's age? *
Teen's gender? *
Preferred pronouns? *
What is the primary reason for your child taking this course? *
What would like to get out of the mindful self-compassion training? *
Has your child been hospitalized for or diagnosed with any mental health related condition in the past year such as anxiety or depression (Note that this does not necessarily preclude your child from participating in the course)? If so, when was this? *
Is your child currently under the care of a therapist? If so, may we contact him/her if we feel that it is warranted? If yes- Please provide contact info for therapist. *
Is there anything else you would like us to know about your child? *
Preferred location? *
Required
Preferred days & times? (I am aiming for a Wednesday but am open to considering other times)
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