Group Therapy Application FormProviding some background information will help guide your free call with Dr. Zia. Please take a few moments to complete the form below before scheduling your call.Select Your Group Class(Required)Note: If you're not sure, you may discuss options with our team during your call. Parenting Emotionally Intense Children - Level 1 Parenting Children with Anxiety Coping With Anxiety for Children / Adolescents Building Blocks - Parenting for Emotional HealthSelect Programming Preference:(Required) Summer Intensive - Daily Regular Programming - WeeklyName of Person Completing This Form:(Required) First Last Name of the child you are seeking help for:(Required)Client Age:(Required)Your Preferred Email Address(Required) Your Phone(Required)Referral Source:(Required)Please briefly describe your presenting concerns(Required) Recommendations will be made after a brief screening call, which will include details on fees associated with treatments and programming suggested. At FFEW we do not offer the following services: psychological assessment; treatment for eating disorders; neuropsychology; treatments for children diagnosed with Autism. If for any reason Dr. Zia feels unable to support you and your goals, alternative referrals will be provided. I have read the above terms:(Required) Yes, I AgreePlease double check your email and phone number above.(Required) Yes, I have checked.IMPORTANT: This is Step 1 of 2. After submitting your form, please wait for the next page to load to schedule your screening call.
