Fall 2021 Self-Regulation Groups
Hi! Use this form to get on our group waitlist for fall of 2021. Groups are to be held on Saturdays. Completing this form does not guarantee your space nor commit you to it.
We will want to discuss whether this is a good fit for your child prior to participation and reserving the space for your child.
We understand that your ability to participate will likely depend on the dates and times of the groups.

Please note: insurance coverage varies by company and plan; insurance often does not cover groups
What is your name? *
What is your email? *
What is the name and date of birth of your child? *
Which group are you interested in? *
Groups are held weekly and if you miss a session we cannot provide a make up. However, we will make sure you have any materials or handouts that may be missed. *
Completion of this questionnaire does not guarantee placement in one of our groups. It also does not commit you to participate. Completion of this form does not establish a client-therapist relationship. *
What is your time preference for a Saturday morning group? *
Do you have any questions or is there anything you feel we should know?
Submit
Never submit passwords through Google Forms.
This form was created inside of Apex Occupational Therapy. Report Abuse