Summer Group Therapy — Interest Form
Let us know your interest in our summer group therapy sessions! Please complete this form to help us learn more about your child and preferences.
Please note: All group sessions are self-pay and are not billed through Medicaid. For questions, call 678-322-8255 or visit therapyworksclinic.com.
Parent/Guardian Full Name
*
First Name
Last Name
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent Email Address
*
example@example.com
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which group are you interested in?
*
Friend Skills Summer Group (social language & peer connection)
Movers & Explorers (sensory regulation & movement)
Not sure yet — help me decide
Which age cohort applies to your child?
*
Ages 3–5
Ages 6–9
Preferred payment option
*
Full 6-session package ($390)
Pay per session ($65/session)
Not sure yet
How did you hear about us?
*
Please Select
Current Therapy Works client
Social media
Friend or family referral
Internet search
Other
Any questions or additional notes?
Submit Interest
Should be Empty: