SPACE Parent Group Interested in joining this group? Please complete the below questionnaire.We’ll reach out shortly to discuss availability and address any questions you might have. Child's Full Name Age School Parent/Guardian's Full Name 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 Pleae rate the severity of these concerns: Mild Moderate Severe Unknown How long has your child struggled with these concerns? Please list any additional suspected or diagnosed mental health concerns (e.g, Depression; ADHD; Learning Differences, etc.): Please describe any/all mental 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? Is there any additional information you'd like to share with us? How did you learn of this group? Submit Share this:Click to email a link to a friend (Opens in new window)