Group Therapy Application Form Providing 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. CEIC - Caregiving Your Emotionally Intense Child CAC - Caregiving Your Anxious Child CWA - Coping With Anxiety CFR - Caregiving For Resilience Select Programming Preference:(Required) Summer Intensive - Daily Regular Programming - Weekly Name 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 Agree Please 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.
