Support Group Youth Questionnaire

Caregiver Names: *

request your Email

Phone *

Email *

Preferred Contact Method: *

What would you like your child(ren) to gain from Back on TRAC?

What support would you like as a caregiver?

Have you contacted the SWAN Helpline to request TRAC Services for Families as your support group provider?

Youth Name *

Pronouns

Relationship to Caregiver *

Age *

Grade *

List a few things your child enjoys or does well:

Does your child have any sensory needs: *

Describe Sensory Needs:

Are there any situations that may cause your child stress or discomfort? *

Describe Triggers or Stressors

Describe what helps your child calm, reset, or shift their behavior. Please provide specific details.

Share anything that helps us understand your child's personality

How comfortable is your child in group settings? *

List anything that helps them feel safe or supported:

Are there any emotional or behavioral needs we should be aware of? *

Describe Emotional or Behavioral Considerations