Enrollment Form: Mastering the Teen Years & Beyond
Hello! I am happy you are interested in having your teen join this fun and interactive group. In order to make sure this group is the right fit for your child's needs, please answer the following questions. Please note, the information you share below will be kept private and confidential in accordance with the United States HIPPA privacy standards. Information shared will be read only by the facilitator, Elizabeth Joy Shaffer, OTD.
Your Name
First Name
Last Name
Your Teen's Name
First Name
Last Name
Parent's or Caregiver's Email
example@example.com
Phone Number
Please enter a valid phone number.
Child's Gender
Female
Male
Transgender
Gender neutral
Non-binary
Prefer not to say
Other
Age
City & Country
How motivated do you feel your teen is in personal development or overcoming current challenges ?
Not at all (but may be open to the idea)
1
2
3
4
Motivated to grow with others
5
1 is Not at all (but may be open to the idea), 5 is Motivated to grow with others
Life rating: How well do you think your teen is doing at school?
Barely getting by
1
2
3
4
Excelling
5
1 is Barely getting by, 5 is Excelling
Life rating: How well do you think your teen is doing socially?
Barely getting by
1
2
3
4
Excelling
5
1 is Barely getting by, 5 is Excelling
What major problem or issue DO YOU FEEL your teen facing at this moment?
What major problem or issue does YOUR TEEN FEEL they are facing at this moment?
How well is your teen handling these problems or issues now?
Not at all
1
2
3
4
Very well
5
1 is Not at all, 5 is Very well
How much is this problem impacting their life now?
Not at all
1
2
3
4
Very well
5
1 is Not at all, 5 is Very well
What is in the way of solving the current problem or issue?
What have you tried in the past to help your teen with this current problem or challenge?
Please list any diagnosis, developmental delays, learning difficulties your child has or is experiencing.
What is your intention for enrolling your teen into this group?
Do you have any questions, concerns, or thoughts you want to share?
Thank you
I will be in touch by email with more details about the upcoming teen group. If you have not received an email from me within 3-days of completing this form, please check your spam folder or contact me be email at elizabeth@therapyintl.com.
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