Mindful Teen Circles (MTC) Interest Questionaire

Thank you for your interest in Mindful Teen Circles. We look forward to hearing from you. Unless otherwise specified, we will respond in one business day to set up a meeting time, provide an overview of the MTC program, and answer any questions. Please read the MTC Participant requirements before completing the interest questionnaire.

MTC Participant requirements

You must have a referral from the Department of Psychiatry at MedStar Georgetown University Hospital in order to participate in MTC at this time. If you do not have a referral, please email Elicia Wright at ewright@iaam-dc.org
You must be between the ages of 12-15 years.

Referred By

Please provide the name of the physician or therapist who referred you to MTC.

Participant Name

First Name

Last Name

Email

Date of Birth

MM

DD

YYYY

I am ...

What is your age?

Gender Identity

What pronoun do you use to refer to yourself?

School

What School do you currently attend?

Teen's Mobile Phone

(###)

###

####

Home Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Line

Parents / Caregiver's Information

Parent | Caregiver Name

First Name

Last Name

Parent | Caregiver Phone

(###)

###

####

Parent| Caregiver 2 Name

First Name

Last Name

Parent | Caregiver 2 Phone

(###)

###

####

Mindful Teen Circles (MTC) Interest Questionaire

MTC Participant requirements

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