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Mindful Connections Youth Program Registration
First Name
Last Name
Email
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
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Phone Number
Birthdate
School & Grade
Parent/Guardian Name
Parent/Guardian Email Addres
Parent/Guardian Phone
Pronouns
She/Her
He/Him
They/Them
Are you currently in counseling?
Yes
No
What kind of loss have you experienced? (select all that apply)
Loss of a loved one
Loss of a pet
Parents are Divorced/Seperated
Moved
Changed Schools
Friendship
Identity
Disability
Illness or Injury
Other
When did your loss(es) occur?
How is your loss affecting you now?
What kinds of social pressures/issues do you feel? (Pick all that apply)
Bullying
Body Image
Academics
Athletics
Drugs & Alcohol
Relationships/Sexual Identity
Friendships
Other
Have you experienced any traumatic events?
Yes
No
If so, please explain.
Have you ever attempted or considered harming yourself?
Yes
No
If so, please explain and share follow-up treatment.
Do you experience fighting in your household?
Yes
No
If so, please explain.
Are you currently taking medications for depression, anxiety, or other mental health issues?
Yes
No
If so, please list.
Do you currently practice yoga?
Yes
No
Please tell us why you're interested in participating in this Mindful Connections Program.
Do you have any injuries or disabilities that will affect your practice?
Yes
No
If so, please list.
Is there anything else you would like for us to know?
How did you hear about CSG?
Register
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