Lego Group - Brick by Brick - Group Registration Form

Thank you for your interest this group! Please complete this form so we can learn more about your child. We will review the information to ensure the group is a good fit, and then follow up to finalize registration.

Please note that information collected on this form will be kept confidential and will not be shared with others outside of our practice.

Child's first name

Child's last name

Child's date of birth

Parent/guardian last name

Email address

Phone number

Please tell us about your child and why you are interested in this group.

Please feel free to share any important information about your child's health, development, and any diagnoses (e.g., ADHD, Learning Disability, Autism).

Each session of this group is 45 minutes long and will involve some cooperative group play. Do you have any concerns about your child’s ability to participate in this type of group?

Has your child attended any of our previous groups at Riverwise, and if so which one(s)?

Do you have any questions about this group?

Your information will be encrypted.

Lego Group - Brick by Brick

Thank you for your interest this group! Please complete this form so we can learn more about your child. We will review the information to ensure the group is a good fit, and then follow up to finalize registration.

Thank you for your interest this group! Please complete this form so we can learn more about your child. We will review the information to ensure the group is a good fit, and then follow up to finalize registration.

Riverwise Psychological Services