CONQUER your Anxiety and Worries for Tweens Intake Form

CONQUER your Anxiety and Worries for Tweens Questionnaire

Facilitator Message

Welcome! We are so excited to have you join us in this Summer Camp session of “Conquer Your Anxiety and Worries”. Miss Alicia has the pleasure to lead this program and she can’t wait to help you discover your own power and begin to conquer your anxiety and worries! Please take a moment to answer the pre interview questions for us. These questions and the answers that you share will not only help us get to know you a little better but will also help Miss Alicia put together a program that will be beneficial for everyone. If you should have any questions please feel free to email Miss Alicia at amcghie@fsca.ca We can’t wait to meet you IN PERSON in August!
Tween's*
First Name Last Name
Tween's Birthday*
Parents Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Contact Information*
Phone Number Email Address
1. What appears to be worrying your tween?*
2. What behaviours is your tween demonstrating that suggest anxiety?*
3. How long has your tween been demonstrating these behaviours?*
4. What is your TWEEN'S level of coping regarding their anxiety symptoms?*
- 1- Has great amounts of difficulty
- 2
- 3- Has some amount of difficulty
- 4
- 5- Feeling confident
5. What is YOUR level of coping regarding your child's anxiety symptoms?*
- 1- Has great amounts of difficulty
- 2
- 3- Has some amount of difficulty
- 4
- 5- Feeling confident
6. Are there any other behaviour concerns?*
7. Does your child have a mental health diagnosis currently?*
8. Is there a family history of anxiety that you are aware of?*
9. Tell me about your child's experience with anxiety in the classroom.*
10. Has your family had any involvement with Child Welfare/Child Protection?*
11. Is there anything else we should know about your child to best support them in the group?*
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