Teens/Tweens Intake Form – Better With Betsy – Betsy Guerra, PhD, LMHC, CHt

Today's Date*
MM slash DD slash YYYY
Child's Name*
First Last
Child's Place of Birth*
Child's Date of Birth*
MM slash DD slash YYYY
Languages Spoken*
- English
- Spanish
- Other
School Name*
Current Grade*
Child's Cell Phone # (if applicable)
Chilld's Email (if applicable)
Address*
Street Address Address Line 2 City Florida ZIP / Postal Code United States
Child's Facebook (if applicable)
Child's Instagram (if applicable)
Child's Snapchat (if applicable)
Mom's Name*
First Last
Mom's Phone Number*
Mom's Email*
Dad's Name*
First Last
Dad's Phone Number*
Dad's Email*
Parents'Relationship Status*
The child lives with the following family members: (include relationship and age)*
What made you register for our Teens/Tweens Leadership Bootcamp?*
What do you hope to get out of this 8-week Leadership Experience?*
Is there a topic you would like for us to cover in order to specifically benefit your child? Explain.
How did you hear about our Leadership Bootcamp?