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Take Action Child Anxiety Group Registration Form
Home
Social and Emotional Group Therapy Programs
Take Action Child Anxiety Group Registration Form
Please enable JavaScript in your browser to complete this form.
1. Child Information
Full Name:
*
First
Last
Date of Birth
*
Age
Gender
*
Male
Female
School/Grade
Preferred Pronouns
2. Parent/Guardian Information
Parent/Guardian 1
Name
*
First
Last
Relationship to Child
Phone Number
*
0 of 10 max words.
Email Address
*
Home Address
Parent/Guardian 2 (if applicable)
Name
First
Last
Relationship to Child
Phone Number
0 of 10 max words.
Email Address
Home Address
3. Emergency Contact Information
Name
First
Last
Relationship to Child
Phone Number
0 of 10 max words.
4. Child's Medical Information
Primary Care Physician
Phone Number
0 of 10 max words.
Allergies
Medications
Any Relevant Medical Conditions
5. Child's Mental Health Information
Anxiety Diagnosis and Treatment
Has your child been diagnosed with an anxiety disorder?
Yes
No
If yes, please specify
Is your child currently seeing a psychologist or psychiatrist?
Yes
No
If yes, please provide the name and contact details
Is your child currently taking any medications for anxiety?
Yes
No
If yes, please specify
Has your child previously attended therapy or a support group for anxiety?
Yes
No
If yes, please describe the experience
6. Primary Concern
What are the main concerns regarding your child's anxiety?
anxiety? or 5.
How does anxiety affect your child’s daily life, such as school, home, or social activities?
7. Symptoms of Anxiety
Can you describe any specific fears or worries your child has?
Does your child avoid certain situations due to anxiety?
How often does your child complain of physical symptoms like headaches, stomachaches, or difficulty sleeping?
8. Current Functioning
How is your child performing academically and socially?
Does your child participate in group activities, or do they tend to withdraw?
9. Previous Interventions
Has your child received any previous treatment for anxiety (e.g., therapy, medication)? If so, what was the outcome?
Is your child currently seeing a psychologist, psychiatrist, or paediatrician? If so, whom?
10. Motivation and Goals
What do you hope your child will gain from participating in this group?
Is your child willing to participate in group discussions and activities?
11. Severity of Symptoms
Has your child exhibited any severe symptoms, such as panic attacks, self-harm, or aggressive behaviour?
Does your child have anxiety so severe that it interferes with their ability to participate in a group setting?
12. Co-Occurring Disorders
Does your child have any other mental health diagnoses, such as ADHD, autism spectrum disorder, or depression?
Are there any learning or developmental issues that might affect their ability to engage in the group?
13. Medication and Medical Conditions
Is your child currently taking any medication for anxiety or other mental health conditions? If so, is it well-managed?
Are there any medical conditions that might impact your child’s participation in physical or group activities?
14. Parental Involvement
Are you able and willing to be involved in your child's program by attending the 30-minute parent session each week?
15. Group Suitability
Does your child have any history of disruptive behaviour in group settings?
Is there any reason to believe that your child might not benefit from or might disrupt the group?
16. Group Participation Information
What are your goals for your child attending this group?
Does your child have any special needs or require accommodations to participate in the group?
Is there anything else you would like the group facilitators to know about your child?
17. Consent and Agreement
I give permission for my child to participate in the Take Action Child Anxiety Group
Yes
No
I understand that I am required to attend the 30-minute parent session
Yes
No
I consent to the group facilitators discussing my child’s progress with their primary care provider/mental health provider if necessary
Yes
No
Signature of Parent/Guardian 1
Date
Signature of Parent/Guardian 2
Date
Submit
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HELENSVALE
Homeworld Helensvale
Shop 51, 502 Hope Island Road
Helensvale, Qld 4212
(07) 5551 0251
NERANG
Prana Centre
Suite 3, 832 Southport-Nerang Road
Nerang QLD 4211
(07) 5668 3490
MOUNT GRAVATT
Mt Gravatt Medical Precinct
SE 105, 1808 Logan Rd
Upper Mount Gravatt QLD 4122
(07) 3102 1366
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