Facing Your Fears Online Interest Form

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Disclaimer:  An integral part of this program is parent/caregiver involvement. Please be advised that a parent/primary caregiver is required to participate in each group session. Additionally, parents/primary caregivers will be responsible for completing weekly homework assignments with their children.

Note: If your child displays behaviours that are disruptive to the group during group sessions, individual service may be recommended at that time.

Information Collection Notice: This intake form is used to determine clinician assignment, suitability of service, and prepare for our initial contact with you. The information collected will be stored in your child’s confidential client record and will only be accessible by those actively involved with your service.


  • Parent/Caregiver Contact Information

  • Child/Teen Information

  • Past Group Experience

  • Learning Readiness

    Please respond as accurately as possible to the following skills.

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