top of page

Refer a Participant for
Group Therapy

This group is for participants ages 11-14. Please only refer pre-teens/teens within this age range. 

Teens With Trauma receives funding from various sources, including federal grants, which allows us to provide free therapy to the teens we serve. To help us maintain these services, please provide as much information as possible on the form below. Participant names will only be shared with our intake coordinator and clinical staff, and will not be disclosed elsewhere. Other demographic information is required for federal reporting purposes. We take participant privacy and security seriously. Please contact us if you have any questions or concerns. 

Referral Form Healing in the Ring - Round 2

Participants must be between the ages of 11-14 to qualify for a spot.

PARTICIPANT INFO

Date of Birth:
Month
Day
Year
Is the participant currently in individual therapy?
Yes
No
Unsure

Please note: Clients currently in individual therapy with Shayla Brown (a therapist at Teens With Trauma) are not eligibleto participate in this group.

Caregiver Contact

Participant Contact (if applicable)

Logistical Fit

Can the participant commit to attending all scheduled sessions from September 13 to December 13?
Yes
No
Does the participant have reliable transportation to and from the group?
Yes
No
If the participant does not have reliable transportation, can you or your organization assist with arranging transportation for the participant?
Yes
No

Clinical Fit

Has the participant experienced sexual abuse or related trauma? (Note: This program is designed for survivors. Details are not required, but confirmation is needed for eligibility.)
Yes
No
Has the participant shown interest or openness to group support or physical movement activities like boxing?
Yes
No

Other Info

bottom of page