ANNOUNCEMENTS

The Color of Pain BIPOC Teen Group

NyLu Therapeutic Solutions, LLC 801 Wayne Avenue, Suite 204 Silver Spring, MD, 20910 (map)

Name

First Name

Last Name

Preferred Name

Preferred Pronouns

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Best Phone #

(###)

###

####

Best Email

Will be used for reminders

Current Grade

What are some stressors you're facing right now?

Stressors = Things that cause you stress

In a few words what are you hoping to get out of the group?

Would you be willing/interested in meeting in-person at times?

By checking this box, you agree to the $40 registration fee for this group.

I agree