Group therapy for young people with social challenges

When:
Wednesday evenings, 6:00 to 7:00 p.m., rolling admission throughout the year.

Where:
Orinda, CA 94563 Tel: (925) 262-3135

Rates:
$90 per session.

Application Submission:
Please fill out the following application. You will be able to electronically upload everything when you click the “Submit Application” button at the very bottom. If you can’t complete the form entirely in one sitting, simply click “Save & Continue Later,” also at the bottom, to temporarily save what you have entered. You will also sign a “Coaching Agreement” when you meet with Meg Fields for your first session.

Application for Living Skills Group

Participant
Name*
First Middle Initial Last
Nickname
Gender and Preferred Pronouns*
DOB*
Age*
Siblings?*
Email
Mobile Phone
Alternate Phone
Family
Father's Name*
First Last
Father's Address*
Street Address City State ZIP Code
Father's Email*
Father's Mobile Phone*
Father's Alternate Phone
Father's Occupation
Mother's Name*
First Last
Mother's Address*
Street Address City State ZIP Code
Mother's Email*
Mother's Mobile Phone*
Mother's Alternate Phone
Mother's Occupation
I/we have carefully read this agreement, and by checking this box and by clicking on SUBMIT APPLICATION below, I/we agree to its terms.*
- I/we agree to application terms
Submit Completed Application
Name
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Application for Living Skills Social Group

Application for Living Skills Group

Participant

Family

Submit Completed Application