Group Programs Waitlist Form

Thank you for your interest in our groups. Please complete this form to be added to our waitlist. Once we have new dates available for groups you have expressed interest in, we will reach out to you by email with details on how to register.

Please correct the errors described below.

Child/Adolescent's Name

Child/Adolescent's Age

Parent's Name

Phone number

Email address

Which group(s) are you interested in? Please visit our website for more information about each group

Ages 6-8: Lego Group

Ages 8-11: Go With The Flow (Cognitive Flexibility Group)

Ages 8-11: Befriend Your Feelings (Emotion Regulation Group)

Ages 9-11: Lego Group

Ages 9-11: Connected Minds (Neurodivergent Girls Group)

Ages 12-14: Focus Forward (Executive Functioning Group)

Ages 12-14: Connected Minds (Neurodivergent Girls Group)

Parents: SPACE Supportive Parenting for Anxious Childhood Emotions Group

Parents: Not What I Expected

Parents: From Assessment to Action Workshop

Parents/Professionals: Free Assessment Webinar

Do you have any questions?

Your information will be encrypted.

Riverwise Psychological Services

www.riverwisepsych.com

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide