Intake Form - Confidence in the Kitchen

Please complete and submit the form below.

You will then be contacted by the facilitator to complete registration.

Group will run weekly from Oct 2 - Nov 6, Thursday evenings 4:30-6:30.

*Participant's Name

*Age

*Parent/Guardian Name

*Phone Number

*Email

*Emergency Contact's Name (other than above)

Emergency Contact's Phone Number:

*Presenting Concerns (check all that apply)

Anxiety

Low self-esteem

Social isolation

Emotional dysregulation

Difficulty coping with stress

Lack of confidence

Other

*Any food allergies?

Yes

If "yes" to food allergies, please provide details below.

Dietary restrictions or preferences?

Any sensory sensitivities or food aversions?

Medical or Mental Health Conditions We Should Be Aware Of?

Does your teen benefit from any accommodations, support strategies, or structure that would help them participate fully in the group?

*How Did You Hear About This Group?

School

Social media

Counsellor referral

Friend/family

Other

CONSENT TO PARTICIPATE (click the check-box to the left): I understand that this is a therapeutic skills group facilitated by a Registered Clinical Counsellor, and not a substitute for individual therapy. I give permission for my child to participate in Confidence in the Kitchen and understand that food will be prepared and consumed as part of the group.

*Signature

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1512 Queensway, Prince George, BC

(236) 331-6106 (call or text)

office_admin@validitycounselling.org

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