Brainiacs Mentoring Program Intake Form

Please fill out all fields.

Applicant Information:

Date of Birth(Required)

Primary Language

Phone(Required)

Tell us how you hope to benefit from joining the program:(Required)

List any Brainiacs groups or programs you have attended.(Required)

Emergency Contact Information:

Phone(Required)

Email(Required)

Important information please read before signing: Brainiacs groups and programs are not a substitute for individual therapy or clinical care.

Communication between you, the group members and the group leaders is both privileged and confidential. This means that group leaders cannot discuss your case orally or in writing, except, as necessary, with other Brainiacs staff. Your group leader has an ethical and legal obligation to break confidentiality under the following circumstances: • If there is a reason to believe there is an occurrence of child, elder or dependent adult abuse or neglect. • If there is reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit. • If there is a court order for release of your records.

Thank you for your interest in our Mentoring Program!

Please fill out all fields.

Applicant Information:

Emergency Contact Information:

Important information please read before signing: Brainiacs groups and programs are not a substitute for individual therapy or clinical care.