Children of Addiction Support Group Interest Form Please enable JavaScript in your browser to complete this form.This is a support group for elementary kids, ages 8-11, who are dealing with a loved one’s addiction issues. This is a six-week group that will run from 5:00-6:00 every Wednesday, beginning October 16th-November 20th. Total cost of the group is $180/six weeks. If you would like to be contacted by Christine Rushford, LMHC to discuss your child’s participation in group, please fill out the below interest form. *Filling out this form does not constitute registration in the group. Name of Child: *FirstLastDate of Birth: *Current Grade in School: *School Child Attends *Person in Child's Life with Addiction Issues: *Parent/Guardian Name: *Email *Phone *Terms of Use *Yes, I want to submit this formBy submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.WebsiteSubmit
