Teen Group Enrollment and Screening Application

Equinox Counseling and Wellness Center

Life and Social Skills the EQ Way
A Therapeutic Club Program

Enrollment and Screening Information

Enrollment information is accepted up to 3-days in advance of the identified group/club start date.

A $100 deposit is required at the time of registration to secure enrollment. Upon completion of the initial screening, the deposit amount will be applied to the cost of the therapeutic Club in which you are enrolling and is non-refundable if participation is cancelled after the start of the group. If is determined the therapeutic social skills club is not be a good fit for your child after the initial screening your deposit can be applied to another event or service that may be more appropriate or be refunded.

Enrollment and Application Information

INSTRUCTIONS: Please review and fully complete each of the forms. Please do your best to complete this packet accurately. Forms must be completed and signed to be considered for enrollment. If you have any questions or concerns, please do not hesitate to call us: 303.861.1916

General Information
How did you hear about groups for troubled teens?*
- Equinox Counseling Website
- Current Equinox Counseling Client
- Current Therapist
- Facebook
- Twitter
- Friend
- Other
Which groups are you interested in for your child?*
If you selected Current Therapist or Current Client, please list their name here.
If you selected Other, please explain here:
Participant Information
Name*
First Last
DOB*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current School Placement (if applicable)*
Current Grade*
Please describe current classroom setting and/or school program: (inclusion, IEP, 1:1 paraprofessional, shared aide, etc.)*
Parent/Guardian Info
Parent #1
Name*
First Last
Primary Contact*
- Yes
- No
Home Phone Number*
Cell Number*
Work Number
Email*
Preferred Method of Contact (check all that apply)
- E-mail
- Phone
Home Address: (if same as applicant, leave blank)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent #2
Name
First Last
Primary Contact
- Yes
- No
Home Phone Number*
Cell Number*
Work Number
Email*
Preferred Method of Contact (check all that apply)
- E-mail
- Phone
Home Address: (if same as applicant, leave blank)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Info
Emergency Contact #1
Name*
First Last
Relationship to Applicant*
Emergency Contact #2
Name
First Last
Relationship to Applicant
Alternate Pick-up
Note: If you plan to ever have someone other than a parent/guardian pick-up your child, you must provide the information below.
Alternate #1
Name
First Last
Relationship to Applicant
Alternate #2
Name
First Last
Relationship to Applicant
Psychiatric/Behavioral History
The following section is to help us better understand and support your child's growth and development. Please complete as accurately as possible.
Has your child ever had psychiatric care and/or received a diagnosis:*
- Yes
- No
If Yes, please explain*
Current Therapist or Treatment Provider
Phone*
Current or in last 6 months: (Please check all that apply):*
- Depressed Mood
- Anxiety
- Sleep Disturbance
- Mood Swings
- Panic Attacks
- Appetite Problems
- Anorexia
- Bulimia
- Aggression
- Hyperactivity
- Weight loss/gain
- Grief/Loss
- Paranoia
- Confusion
- Hallucination
- Delusion
- Isolation
- Elevated Mood
- Fatigue
Behavior and Personality: (Please check all that apply):*
- Conduct Disorder
- Impulse Control Disorder
- Oppositional Defiant Disorder
- Obsessive/Compulsive Disorder
- Reactive/Attachment
General Behavior
In the past 6 months, has your child displayed any of the following? (Please check all that apply)*
- Intentionally broken other people’s property
- Opposition/Excessive Rule Breaking
- Tantrum
- Physical Agression
- Verbal Abuse
- School Problems
- Running Away
- Curfew Issues
- Social Media/Electronics Addiction
- Excessive lying
- Stealing
Has your child previously or currently demonstrated sexual boundary or behavior problems?*
- Yes
- No
If you selected Yes, please explain*
Has your child exhibited any self-injurious behaviors, suicidal ideation, or had past suicide attempts?*
- Yes
- No
If you selected Yes, please explain*
What coping skills does your child currently utilize when feeling upset, anxious, nervous etc…*
Chemical/Substance Abuse
Past or present use of illegal drugs, chemicals, prescription drugs, alcohol, or tobacco?
- Yes
- No
If you selected Yes, please describe:*
Has your child been involved with dealing drugs?
- Yes
- No
If you selected Yes, please describe:*
Has your child ever been in a drug treatment or residential program?
- Yes
- No
If you selected Yes, please describe:*
Learning
Learning: (Please Check all that apply)*
- Dyslexia
- Dyscacula
- Dysgraphia
- Other
If you selected Other, please list it here:*
Does your child have specific learning accommodations utilized in the school environment?*
Legal History
Is your child currently involved in legal action or probation?
- Yes
- No
If you selected Yes, please describe:*
Has your child ever been arrested, charged, or convicted of a crime?
- Yes
- No
If you selected Yes, please describe:*
Probation/Parole Officer
First Last
Probation/Parole Office Phone Number
Social Profile
How many hours of "screen time" does your child engage in each weekday? {TV, computers, phones, tablets, video games, etc}:
Per Day*
How many hours of "screen time" does your child engage in each weekend? {TV, computers, phones, tablets, video games, etc}:
Per Day*
What time does your child go to bed?*
What time does your child wake up?*
Does your child wake up throughout the night? (how often)*
Would you describe your child as:*
- Extraverted
- Introverted
- Mixed
Please describe your child’s ability to solve problems and any specific strategies he or she has to do so:*
Please indicate the way your child interacts with peers and adults:*
- Respectful of adults/easily responds to limits
- High conflict with adults/authority figures
- Has one main friend
- Seeks out a healthy group of friends
- Easily influenced and seeks out negative peer group
Please check all words that describe your child: (circle all that apply):*
- Affectionate
- Nervous
- Anxious
- Talkative
- Fearless
- Follower
- Leader
- Melts Down
- Cries Easily
- Quiet
- Sad
- Fearful
- Shares Easily
- Very Active
- Even Tempered
- Restless
- Friendly
- Shy
- Confident
- Aggressive
- Happy
- Sensitive
- Careless
- Immature
- Cheerful
- Independent
- Guarded
- Daydreams
- Eager to Learn
- Easily Tempted
- Others
If you selected Others, please list it here:*
Medical & Health Profile
Are your child’s immunizations up to date?*
- Yes
- No
If No, do you have a state exemption?*
- Yes
- No
Is your child diabetic?*
- Yes
- No
If Yes, does your child take insulin?*
- Yes
- No
Please list all allergies: food allergies, medications, bees, animals, seasonal etc….*
Is your child on a special diet/restricted from foods?*
- Yes
- No
If Yes, please explain:*
Medications: Please identify the names of the medications your child is currently taking and include dose, time and prescribing physician.*
Is your child able to take medication independently?*
- Yes
- No
Date of last physical/medical exam:*
Does your child have any physical limitations we should be aware of which may inhibit athletic or adventure based activities?*
Enter Promo Code:
Parent Signature*
Date*
MM slash DD slash YYYY

Enrollment and Application Information

General Information

Participant Information

Parent/Guardian Info

Emergency Contact Info

Alternate Pick-up

Psychiatric/Behavioral History

General Behavior

Chemical/Substance Abuse

Learning

Legal History

Social Profile

Medical & Health Profile