Winter 2020 Executive Function Groups at Meghan Barlow and Associates
5 Week Series 1/7, 1/14, 1/21, 1/28, and 2/4 Ages 9-11: 4-5pm Ages 12-14: 5-6pm
In a fun setting with peers, participants will be introduced to new and innovative strategies targeting key executive skills, including planning, time management, organization, and homework & study strategies.
Email address *
Parent/Caregiver First Name *
Parent/Caregiver Last Name *
Child First Name *
Child Last Name *
Child's Date of Birth *
Phone number *
Street Address *
City *
State *
Zip Code *
Primary diagnosis, if any. *
If yes, please provide any additional information:
How did you hear about us? *
Are you currently seeing a provider at Meghan Barlow and Associates or elsewhere? *
Does child have any medical conditions or history of seizures? *
Does child have any food allergies or sensitivies? *
Does child have any other allergies? *
Emergency contact (name and contact number) *
Describe child's strengths and personality. *
How would you like to pay? *
Card number *
Expiration *
3 or 4 digit security code *
Zip code associated with card *
Name on card *
Program Information, Terms, and Agreement
All programs will take place at the offices of Meghan Barlow and Associates, unless otherwise noted. If you register and are unable to attend, we regret that we can not offer refunds for cancellation; however, you will be provided with a credit for future workshops, groups or services with the same provider. (Katie Greenleaf, MA, LPCC) The cost of attendance is $475 and is due upon registration. Your credit card will be billed and a receipt will be emailed to you. If you would like a detailed invoice, please contact us. Please feel free to call Katie Greenleaf with any questions. (440) 263-6773 *Please check your email inboxes for a welcome email during the week prior to the start of group.
Please select 'yes' to acknowledge you have read the terms and information above and type your signature below to indicate agreement. *
Please type your full name and submit form. *
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