Please check Group Announcements for changes and updates.

Adolescent Intake Form

Thank you for your interest in our Adolescent support groups. The purpose of this screening is to determine if re:MIND services are a good fit for your adolescent's needs. The group is a safe place for adolescents to talk about coping skills, process feelings, and provide support to their peers. These groups are led by a trained facilitator and are professionally monitored and managed. Our services are best utilized as only one part of an overall wellness plan which may include therapy, medication, counseling, etc.

Please complete this form to the best of your ability based on your adolesecent's behavior in the most recent month.

Adolescent Demographics

Diagnosis and Treatment

Describe briefly your main concern about the adolescent

Signs and Symptoms

On a scale of 1-5, (1 being none of the time and 5 being all the time), rate your adolescent on these items in the last month:

Peers, School, Support Group

Parent/Legal Guardian Questions

Emergency Contact (other than legal guardian)

List Emergency contact other than legal guardian if you are unavailable

What happens next

You will be redirected to the Parent/Guardian and Adolescent Consent Form. The consent form is required for us to move forward with the application. A Program staff will review application (this intake form and the re:MIND electronic consent). The parent/legal guardian will then be notified by e-mail within 5 business days of initial screening.  Once the adolesent is accepted, group logistics will be provided. For the adolescent to attend group, the parent/legal guardian must be present in the building during group time. The adolescent and parent/legal guardian must also complete the weekly sign in sheet for the in person group.