Social Group Interest Form

Please note that filling out this form does not guarantee enrollment. All enrollments are subject to clinician approval and payment in full is required to finalize registration.

Name

First Name

Last Name

Child's Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

What are you hoping your child is able to work on in group?

What days and times is your child available during the week?

Please note that we are able to run groups Monday-Thursday, 8am-6:30pm

What support(s) would your child need/benefit from while participating in group?

Does your child currently receive therapy at NETC?

Yes