Interest Form for Sibling Support Group

Please complete this secure form to help me better understand you and your tween. Please note: completing this form does not guarantee a spot in the group nor constitute a therapist-client relationship. You will receive an email response from Liz Gray within 24-48 business hours. Please add liz@lizgraycounseling.com to your address book. Thank you!

All questions refer to the tween you would like in the sibling support group.

1) Your name

2) Relationship to Tween

3) Email

4) Phone

5) Tween's name

6) Tween's DOB

7) Tween's School

9) Names of family members, ages, relationship to tween, and if they live in the home.

10) Please describe how having a child with special needs impacts your family- and specifically, your tween?

11) Current and previous medications (write N/A if not applicable)

12) Allergies (write N/A if not applicable)

15) If "yes" to the above question, please describe.

17) If "yes" to the above question, please describe.

19) If "maybe" or "no" to the above question, please describe.

20) Any questions for Liz or anything else you'd like me to know?

Thank you! Make sure to click "SUBMIT" below and please add liz@lizgraycounseling.com to your address book.

- Liz Gray, LCSW, RPT

Completing this form does not guarantee a spot in the group nor constitute a therapist-client relationship. If at any time during the process of completing the form, 15-minute phone consultation, or the intake session I am unable to offer your child a spot in the group, I will discuss other options (which may involve outside referrals). If there are not enough members who sign up for the group, I will discuss additional options with you as well. Thank you for understanding!

Your information will be encrypted.

Interest Form for Sibling Support Group

All questions refer to the tween you would like in the sibling support group.

Thank you! Make sure to click "SUBMIT" below and please add liz@lizgraycounseling.com to your address book.

- Liz Gray, LCSW, RPT

Liz Gray, LCSW, RPT

Licensed Clinical Social Worker & Registered Play Therapist, Liz Gray Counseling, LLC