Group Registration Form

Today's Date

Please check the box of the group you are registering your child for:*

**If your child is not attending therapy session at Emerge, we will be in touch with you to set up a brief free screening to determine if this program is a good match for your child.**

Child's First Name*

Child's Last Name*

Date of Birth*

Child's Age

Type of Insurance:

Caregiver(s) Name and Relationship to Child*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone

Email Address*

How did you hear about this group?*

My child attended (school) this year.

N/A

S/He will be attending (school) in the fall.

Grade

Does your child receive any special services at school?

Please list all

Does Your Child?

Attend therapy sessions at Emerge?

Yes
No

Receive services elsewhere?

Yes
No

If so, where? (Please attach a copy of a recent report.)

Have any allergies?

Yes
No

If yes, please list:

Does your child currently receive psychological services?

Currently
Previously

Where?

I am interested in enrolling my child in a group program because (please specify which group):

My child demonstrates challenges regarding:

Strategies that help my child:

List any sensory processing challenges that your child has:

List any communication and/or social challenges that your child has:

List any diagnoses (formal or informal) that your child has:

List any dietary restrictions that your child has:

Fill Out the Group Registration Form

Fall 2020 Group Registration Form

Does Your Child?