Name *

Phone (Optional)

Email address *

What is your child's name/age *

What is your child's favorite activity? *

What is your child struggling with? *

Does your child have a mental illness? *

Workshop days will be Tuesday-Thursday, will those days work for your child to attend? *

Would your child be available for all 6 one hour sessions? *

are you willing to provide feedback that can be used for future testimonials? *

What Social Media does your child participate? *

Please tell me a little about your child - All information will be confidential. *