Cart
0
What's On
Services
NEWS
For Practitioners
About
Contact
Shop
Back
1:1 Therapies and Treatments
Acorn Children's Clinic
Pain Relief Clinic
Community Clinic
Classes and Workshops
Teen Mental Health Support
Back
About
The Anderida Project
Practitioners
Testimonials
Back
Appointments
Practitioners
Contact
Cart
0
What's On
Services
1:1 Therapies and Treatments
Acorn Children's Clinic
Pain Relief Clinic
Community Clinic
Classes and Workshops
Teen Mental Health Support
NEWS
Bringing health to our community
For Practitioners
About
About
The Anderida Project
Practitioners
Testimonials
Contact
Appointments
Practitioners
Contact
Shop
Confidential Application Form:
To book a place for any of our Teen Support Services, please complete the registration form below.
Which sessions are you applying for?
*
1-to-1 Art Counselling
Self Exploration Group Workshops
Name of Participant
*
First Name
Last Name
Date of Birth / Age
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Parent(s) / Carer
*
First Name
Last Name
Relationship to Participant
*
Email
*
Phone
*
(###)
###
####
Alternative Emergency Phone Number(s)
*
School Attending:
*
Is there a reason your child/ charge wishes to attend the course?
*
Does your child/charge have any specific needs or mental health history that you think may be useful for me to know?
*
We may contact you by phone for more details.
Are there any physical needs or allergies that I need to take into consideration?
*
Do they have any concerns or queries that I can help address?
*
This space is for any other information you would like to share (optional)
FOR GROUP WORKSHOP PARTICIPANTS: (required) - This is a confidential group and all participants will be asked to sign an agreement which states they will not share any information about other members and will be respectful and courteous to each other. As a safeguarding measure I reserve the right to contact external parties if I feel that a participant is at risk of harm to themselves or others.
Yes, I understand
Signed:
*
Thank you!
