Teen Support Group Intake Form

Please complete this form to join Light on Anxiety's Teen Support Group
Name of Participant*
First Last
Email of Participant*
Date of Birth of Participant*
Date Format: MM slash DD slash YYYY
Phone Number of Participant*
What are your teens goals for attending this group?*
How has anxiety impacted your teen or stood in the way of their goals?*
Emergency Contact Information
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Consent & Acknowledgement
By clicking below, I indicate that I understand LIght on Anxiety's Group Treament Confidentiality Rules.

By Signing Below, I indicate that the above information is accurate to the best of my knowledge.
Consent*
I give permission for Light on Anxiety to contact and share information with my emergency contact if Light on Anxiety is concerned for my safety or anyone else's safety.
You have the right to confidentiality and privacy when attending a Light on Anxiety treatment group. Confidentiality within the group setting is a shared responsibility of all members and leaders. While group leaders may not disclose any client communications or information except as provided by law, group members’ communications are not protected. As such, confidentiality within the group setting is often based on mutual trust and respect. It is expected that all Light on Anxiety treatment group members refrain from disclosing any information shared by other group members.*
I agree to Light on Anxiety group treatment confidentiality rules and requirements.
Signature of Participant*
Date*
Date Format: MM slash DD slash YYYY

Emergency Contact Information

Consent & Acknowledgement