First Name * Last Name * Address * City * Zip Code * Phone * E-Mail * Names and Age of Children For Parenting Groups: What is your biggest struggle as a parent? Are there Stepchildren in your family? Yes No WOMEN COPING WITH DEPRESSION Yes No EARLY CHILDHOOD PARENTING Yes No PARENTING THE 5-12 YEAR OLD Yes No PARENTING PRETEENS & TEENS Yes No For Depression Group Only: Are you seeing a Therapist? Yes No For Depression Group Only: If in Therapy, please give name of Therapist? For Depression Group Only: Are you on any Medications? Yes No Do you feel you need to meet with the Facilitator before the group begins? Yes No What is your Church Affiliation?

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