Build & Belong Teen Support Group

Strong & Belong is a support group for youth ages 13-18 who have experienced abuse. It is an opportunity for youth to connect with peers, learn coping skills, build healthy relationships, and gain a better understanding of resources available to help them heal.

Name(Required)

First

Last

Date of Birth

Age

If Date of Birth is unknown

Sex(Required)

Gender Idenity

Race

Ethnicity

Street Address

City

State

ZIP Code

Phone Number

Please include area code

Email(Required)

Enter Email Confirm Email

Reason for Referral(Required)

Parent/Guardian Name

Relationship

Phone number

Please include area code

Email address

Street Address

City

State

ZIP Code

Phone Number

Please Include Area Code

Parent/Guardian Name

Relationship

Phone number

Please include area code

Email address

Street Address

City

State

ZIP Code

Referral Source

Address

City

State

ZIP Code

Phone number

Please include area code

Email address

Fax number

Please include area code

History

Significant events in history (divorce, loss of a loved one, traumatic events)

Past/Present Interventions

Short/Long Term Goals

Grade

Receives Special Education Services

School Name

City

State

ZIP Code

School Phone Number

Please Include Area Code

School Fax Number

Please Include Area Code

Name of school contact/Case manager

School contact/Case Manager email

School contact/Case Manager phone number

Please include area code

Build & Belong Teen Support Group

Build & Belong Teen Support Group

Wisconsin Headquarters

Minnesota Headquarters

Viroqua Offices

Black River Falls Offices

Sparta Offices

Mailing List

Mailing List

Social Media