TTRPG Intake Form

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TTRPG Intake Form

TTRPG Intake Form

Hello, please fill out and submit this form for our Table Top Role Playing Game Group. This form takes approximately 1-2 minutes to complete. Do not use this form in case of emergency or if you or your child are feeling suicidal. Instead, please call 911, go to your nearest emergency room, or contact the national suicide hotline at 800-273-TALK (8255).

HIPAA

Compliance

1
Who is this group request for?* This field is required.You can request this appointment for yourself or on behalf of someone else. Please choose below.
Me
Someone Else
2
Your Name* This field is required.
First Name
Last Name
3
Your Email* This field is required.
example@example.com
4
Your Phone Number* This field is required.
Please enter a valid phone number.
5
Date of Birth* This field is required.
Date
Year
Month
Day
6
Is the potential group member a minor?* This field is required.
Yes
No
7
Potential Group Member's Name* This field is required.
First Name
Last Name
8
Potential Group Member's Email
example@example.com
9
Potential Group Member's Phone Number
Please enter a valid phone number.
10
Potential Group Member's Date of Birth* This field is required.
Date
Year
Month
Day
11
What are the main concerns you are hoping the group will address?* This field is required.Please select all applicable concerns.
ADHD
Anxiety
Asperger's Syndrome
Behavioral Issues
Depression
Family Conflict
Impulse Control Issues
Mood Disorders
Peer Relationships
Relationship Issues
School Issues
Self-Esteem
Stress
Trauma
Other
12
What is the potential group member's schedule availability?* This field is required.Please indicate all possibilities. The wait time is longer for evening hours.
I am flexible.
Monday Morning (9am-12pm)
Monday Afternoon (12pm-3pm)
Monday Evening (3pm-7pm)
Tuesday Morning (9am-12pm)
Tuesday Afternoon (12pm-3pm)
Tuesday Evening (3pm-7pm)
Wednesday Morning (9am-12pm)
Wednesday Afternoon(12pm-3pm)
Wednesday Evening (3pm-7pm)
Thursday Morning (9am-12pm)
Thursday Afternoon (12pm-3pm)
Thursday Evening (3pm-7pm)
Friday Morning (9am-12pm)
Friday Afternoon (12pm-3pm)
Friday Evening (3pm-7pm)
Saturday Morning (9am-12pm)
Saturday Afternoon (12pm-3pm)
13
Have you ever had experience with table top games or Dungeons and Dragons before?
No Experience
Some Experience
Significant Experience
14
What are the goals/concerns to work on through this group?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
15
How did you hear about us?
Should be Empty:

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