Client Name *

First Name

Last Name

Phone Number (Optional)

(###)

###

####

DOB *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Are you available Tuesdays at 11:00 AM from July 5 through mid-August? *

Yes

No

Is your child able to participate in a group setting with up to 7 peers? *

Yes

No

Unsure but willing to try

Is your child currently in individual therapy?

Yes

No

Are you planning to use insurance or pay out-of-pocket? *

Insurance

Out-of-pocket