Thank you for your interest in PTCTM groups! Please take a moment to complete the form below.Please enable JavaScript in your browser to complete this form.Caregiver/Parent First Name *Caregiver/Parent Phone *Caregiver/Parent Email *Preferred Communication:CallTextEmailAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChild's Name *FirstLastChild's Date of Birth *Insurance *My child has Oregon Health Plan (add ID# below)My child is uninsured or has commercial insurance and I would like more information about eligibility for PTC groupOHP ID #Behaviors of Concern *NoncomplianceAcademic ProblemProblems with PeersSocial SkillsDepressionAnxietyAggressionAdjustment DifficultiesOther (list below)List Other Behaviors of ConcernPreferred group time: (Check all that apply) *MorningAfternoonEveningPreferred group modality: *In PersonVirtualEitherHow did you hear about PTC?OtherProvider ReferralWord of MouthFlierOnline SearchEmailSubmit
