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Douglas County Foster/Kin Parent KEEP Group Interest Form

Thank you for your interest in Oregon KEEP® groups! Please take a moment to complete the form below, or you can contact the Douglas County coordinator directly:

Options Counseling
Michelle Wissel
michelle.wissel@options.org
541-510-2099

Name: *

First

Last

County of Residence:

Phone

Contact Email:

Best method of contact:

email
phone

Best time of day for us to contact you:

Ages of foster or kinship children in your home:

Best days of the week and times for group (please check all that apply):

Monday Morning
Monday Afternoon
Monday Early Evening
Tuesday Morning
Tuesday Afternoon
Tuesday Early Evening
Wednesday Morning
Wednesday Afternoon
Wednesday Early Evening
Thursday Morning
Thursday Afternoon
Thursday Early Evening
Friday Morning
Friday Afternoon
Friday Early Evening
Saturday Morning
Saturday Afternoon
Saturday Early Evening
Sunday Morning
Sunday Afternoon
Sunday Early Evening

Accommodations:

ASL Interpreter
Captioning
Other

Please describe other accommodations:

(Optional) Anything else you'd like us to know?

Name

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