480-668-8301
1745 S. Alma School Rd Suite 230
Mesa, AZ 85210
  Toll Free: 1-800-614-8142

Art therapy summer course for teen girls registration

 

                                                                                                                                                                                               

 

 

PLEASE DO NOT ENROLL FROM A MOBILE DEVICE. REGISTRATIONS PERFORMED VIA MOBILE DEVICES OFTEN DO NOT PROCESS COMPLETELY.    
Participant Information    
Teen's Name:
Date of Birth:
Grade in School:
Name of School:
Teen's Phone Number:    Not Applicable
Teen's Home Address:
Who does the teen live with?:  Mother  Father  Both  Other
What are teen's interests?:
     
Parent/Guardian Information    
Primary Parent/Guardian Name:   
     Relationship:  Mother  Father  Guardian/Other
     Email:
     Phone Number:
     Preferred Method of Contact:  Phone  Email 
     
Additional Parent/Guardian Name:
     Relationship:  Mother  Father  Guardian/Other
     Email:
     Phone Number:
     Preferred Method of Contact:  Phone  Email 
     
Parent's Marital Status:
     
Do you have BCBS Insurance?:
     If yes:    
     Member ID#:
     Group #, if applicable:
     Subscriber's Name:
     Subscriber's Date of Birth:
     Subscriber's Employer:
     Subscriber's Relationship to Participant:
     
Emergency Contact Information    
Name:
Relationship to Teen:
Phone Number:
     
Teen Questions    
Have you had, or are you now having, any experience with counseling?:
If yes, how was it helpful or not helpful?:
Do you have a history or present experience with depression and/or anxiety? Select all that apply:  Depression  Anxiety  None
If yes, please share a little about this:
Do you have a history of suicidality (thoughts, actions, or attempts)? Select all that apply: None
Yes, Suicidal Thoughts
Yes, Suicidal Actions
Yes, Suicidal Attempts
Do you have a history of self-harming behaviors (cutting, substance abuse, eating disorder, etc.)?: None
Cutting
Substance Abuse
Eating Disorders
Other
If yes, please share more about this and any actions you are taking to get help or support:
Do you have a history of any kind of physical, emotional or sexual abuse? Select all that apply: None
Physical Abuse
Emotional Abuse
Sexual Abuse
     
Parent/Guardian Questions    
Do you have any specific concerns about your daughter, that would be helpful for Brittany to know about, while your teen participates in this intensive?:
Any other questions you have specific to this art therapy intensive that Brittany can help you with?:
  
I understand that the cost of this Art Therapy program will be $400 and is collected prior to the start of group. If I have Blue Cross Blue Shield, I will be required to pay my portion prior to the start of this course.:

 Yes