Interested in joining this group? Please complete the below questionnaire.Upon receipt, we’ll reach out to answer questions and discuss next steps. Child's Full Name Age School Parent/Guardian's Full Name State of Residence Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Parent Phone Parent E-mail Preferred contact: Phone E-mail Please provide some basic information about your household (e.g., marital status; whether parent(s) work inside or outside the home; siblings/ages; whether child spends time in one vs. two households; etc.): My child struggles with: Anxiety OCD These concerns are: Formally diagnosed Suspected My child tends to struggle with: Separation from parents/caregivers Sleep/bedtime concerns Social situations/demands Performance and/or perfectionism Germs/cleanliness Rigidity/compulsivity Other concerns Please rate the severity of these concerns: Mild Moderate Severe Unknown In attempts to reduce my child's anxiety, I/we tend to: Do things I wouldn't otherwise do NOT do things I would normally do Reduce or eliminate certain demands Adhere to specific/rigid rituals or routines Answer questions repeatedly Other None of the above Please list any additional suspected or diagnosed mental health concerns (e.g, Depression; ADHD; Learning Differences, etc.): Please describe any/all mental health services you've sought in hopes of reducing your child's anxiety and/or OCD (e.g., individual therapy; medication; parent consultation, etc.): How effective have you found these interventions? (enter "N/A" if you've not sought prior treatment) If your child is currently in individual therapy, are you comfortable sharing with your child's provider the fact that you may participate in this parent group? Yes No Not applicable What would you hope to get out of this group? Do you have a preference for how we meet? In-person Virtually I'm flexible Please enter below any additional information you'd like to share and/or questions you have at this time: How did you learn of this group? Submit Share this:Click to email a link to a friend (Opens in new window)