Name of the person completing this form *

First Name

Last Name

Phone number of the person completing this form *

(###)

###

####

Additional caregiver to attend the group

First Name

Last Name

Phone number of additional caregiver attending the group

(###)

###

####

Groups *

Which group(s) are you interested in (you may choose more than one)

S.P.A.C.E. Parenting Group for Anxious Children (Corte Madera)

S.P.A.C.E. Parenting Group for Anxious Children (San Francisco)

ADHD Parenting Group

What symptoms or challenges are you hoping to address? Select all that apply to the youth during the past 3 months.

Anxiety or excessive worry

Panic / panic attacks / fears

Depressed mood

Isolation

Extreme or rapidly changing emotions

Anger

Aggression

Oppositional-defiance

Thoughts of suicide (if your child is at imminent risk, please use crisis resources or dial 911)

Non-suicidal self-harm

School refusal

Friendship / relationship problems

Family relationship problems

Academic stress and/or underperformance

Perfectionism

Inattention / distractibility

Hyperactivity / impulsivity

Eating disorder

Trauma or significant stressor

Substance abuse

Obsessive thoughts

Repetitive behaviors

Poor social skills

Developmental delays that impact current functioning

Autism or autistic-like behaviors

Is your child/adolescent currently in individual therapy?

No

Yes - with a Bridge to Bridge provider

Yes - with a provider from outside Bridge to Bridge

Has your child/adolescent been treated in any of the following settings (check all that apply)? *

Medication management with a psychiatrist

Previous psychotherapy

Intensive Outpatient Programs (IOP)

Partial Hospitalization Programs (PHP)

Psychiatric hospitalization

Residential Treatment

None of the above

Is the patient seeking treatment insured by Medicare?

Yes

No