Group therapy for young people with social challenges

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

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. If you can’t complete the form entirely in one sitting, simply click “Save & Continue Later,” 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
1st Parent or Alternate Caregiver*
First Last Relationship
Home Address*
Street Address City State ZIP Code
Email*
Mobile Phone*
Alternate Phone
Occupation
2nd Parent or Alternate Caregiver*
First Last Relationship
Hiome Address*
Street Address City State ZIP Code
Email*
Mobile Phone*
Alternate Phone
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
Comments
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