Holiday Hours

Parent/Caregiver Names:

Marital Status:

Child’s Name:

Child’s age:

Child’s DOB:

Child's Grade in School. *Please note this group is for children in grades K-12:

Email:

Phone:

Please list the U.S. state you will be located in during the group:

The SPACE group is open to residents of any of the 32 states where psypact has been enacted. Psypact is a program that allows licensed therapists to practice virtually in approved states. See the web page to ensure that your state is included.

Participants

Who is seeking to participate in the SPACE group? (Please specify each participant’s relationship to the child.)

Diagnosis

Has your child ever been diagnosed with a mental health disorder? If so, please explain:

Treatment

Is your child involved in any mental health treatment (i.e., parent coaching, individual therapy, medication management, family therapy, etc.?) If yes, please list the name of the treatment provider and type of treatment.

Hospitalization

Has your child ever been referred to or participated in an intensive outpatient treatment, partial hospital program, or inpatient hospitalization? If yes, please explain and include dates of treatment.

School Attendance

Is your child currently attending school (remote or in person?) Has your child ever struggled to attend school consistently?

Anxiety

What are the ways that your child’s anxiety is interfering with family/parent functioning?

How did you hear about this group?

Please let us know how you learned about this group - Ross Center newsletter, website, recommendation from therapist/psychiatrist/pediatrician (please include the name), etc.

If you were referred by a mental health professional, kindly include their name and email address below:

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Email

This field is for validation purposes and should be left unchanged.

Washington, D.C.

Northern Virginia

New York, NY

Rx Refill Request Form

Rx Request Form

REACH Screening Form

REACH Form

Supportive Parenting for Anxious Childhood Emotions (SPACE) Screening Form

SPACE Form