Group Interest Form

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Group Interest Form

We frequently will offer groups focused on a variety of skills based on interest. Please fill out this form to indicate what groups you may be interested in for your child and your availability. We will add you to our contact list and will reach out when we have an opportunity that matches your interests!

Email *

Record my email address with my response

Child's Name *

Child's Date of Birth *

Please check any areas that you would be interested in your child working on in a group setting. *

Fine motor skills

Poor body awareness

Difficulty sharing

Physical aggression

Accepting changes

Transitioning between activities and places

Motor coordination

Emotional regulation

Direction following

Appropriate peer interactions

Impulse control

Picky eating

Improving confidence

Other:

Required

Parent Name *

Parent Phone Number *

Schedule Preferences

Anytime

Mornings (8:00-11:30)

Midday (11:30-2:30)

After-school (2:30-6:00)

Monday

Tuesday

Wednesday

Thursday

Friday

Is there anything else you would like us to know about your interest in groups for your child?

Preferred method of contact about groups *

Phone

Please make sure to follow us on facebook for more information about our groups and for helpful tips & tricks!

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