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 Please list any additional suspected or diagnosed mental health concerns (e.g, Depression; ADHD; Learning Differences, ASD; etc.): Please list any/all mental health interventions you've sought to-date in hopes of managing your child's anxiety or OCD (e.g., individual therapy; medication; parent consultation, etc.): Please describe the perceived efficacy/outcome of your treatments-to-date (enter "N/A" if no prior treatment): Is your child currently participating in individual therapy, to help manage anxiety? Yes No We're pondering and/or on a waiting list 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 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 My child's anxiety impacts /complicates (check all that apply): Our morning routine Their school day / academics / homework Meal times Our evening routine Bedtime / sleep Bathroom / toileting Social interactions Separation Activities related to daily functioning Other On average, how much time do I spend per day managing (or engaged in) my child's anxiety? Fewer than 30 minutes/day 30-60 minutes/day 1-2 hours/day 2+ hours/day I see my child as being less independent than I'd hope/expect at this age. True False I'm not sure The below-described interaction is a typical example of what triggers my child's anxiety and how I subsequently respond/interact: When interacting with this child, what am I doing differently for this child, compared with what I do for his/her/their siblings? If my child is an only child, what am I doing for him/her/them that I'd rather not have to do? If my child were not anxious or afraid, what would I be doing differently (generally and/or in specific settings/circumstances)? 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: I've read "Breaking Free from Child Anxiety and OCD" by Eli Lebowitz, PhD True story! Working on it... Nope Not yet, but it's on my to-do list How or from whom did you learn about this group? Submit Share this:Click to email a link to a friend (Opens in new window)
