First Name *

Last Name *

Phone *

Email *

Age of participant *

City

State *

Select which group you are interested in.

What are you hoping to get from a skills group?

Briefly describe the main challenges you or your teen are currently experiencing.

Are there any current safety concerns such as active self-harm, suicidal behavior, or severe crisis?

Yes

If yes, briefly explain (including whether this is current or in the past).

Preferred group format.

Preferred group times.

Anything else you’d like me to know when considering group fit?

I understand that completing this form does not guarantee placement in a group.
I understand that skills groups are educational and skills focused in nature and are not a substitute for individual therapy or crisis services.
I understand that submissions are reviewed for clinical fit and I will be contacted regarding next steps if appropriate.