Child/AdolescentGroup Therapy Intake Form Child's Information * First Name Last Name Date of Birth * Parent/Guardian Information * First Name Last Name Email * Phone (###) ### #### Rate * You can select the rate that best fits your current economic situation. We trust you to make the choice that feels right for you. $30 per session $40 per session $60 per session Group * Pre-teen Processing Group Children Aged 8-12 for CBT Group : Addressing Depression and Anxiety Adolescents Aged 12-17 for CBT Group (Addressing Depression and Anxiety) Teen Processing Group Children Group (Focusing on Learning Disabilities) Adolescent Group (Focusing on Learning Disabilities) Adolescents on the Spectrum (Social-Emotional Learning) Youth Depression/Anxiety Processing Group Availability * Please provide five dates and times that you are available for a virtual or in-person intake appointment: Important Information * All intake sessions are 30 minutes in length. There is a non-refundable fee of $45 for the intake session. Please note that participation in the group is not guaranteed after the intake session. If it is determined that the group is not a suitable fit, we will provide appropriate referrals to other services or resources. I understand and agree to the terms. Thank you!
