B.Well Inquiry Form
B.Well serves children who are between 4th and 7th grade. The program consists of six 75-minute sessions which meet in the afternoons during the school year.

This program is a qualified medical expense that can be reimbursable through PPO health insurance, FSA, or HSA.

Please note that B.Well groups are formed based on children's age and grade, and requesting to join the program through this form does not a guarantee that a session will be available. Staff will review registrations on a rolling basis and reach out to you with confirmation or further information.

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Child’s full name
Child’s gender
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Child's birthdate
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DD
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YYYY
Child's current grade
Child’s current school
Parent(s’) Name(s):
Parents’ marital status:
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Parent email address
Parent phone number
Are there any particular areas of challenge, need, or growth for your child that you are hoping to have met by the B.Well program? If so, please describe.
How did you hear about the B.Well program?
Thank you!  We will reach out to you once we have scheduled the next  session for your child's age group.
Please note that groups are formed based on children's age/grade and areas of growth. Bankside staff will review registrations on a rolling basis and reach out to you with confirmation or further information. Once we do reach out to you with confirmation, we'll provide you with a link to register for the session. At that time, you can choose to pay either a nonrefundable $150 deposit (with the remaining $450 due at the first group session) or to pay the program fee in full.
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