Thank you for your interest in the LEGO®-Based Therapy Group

This 12-session group combines play, creativity, and movement to help children build confidence and strengthen social, emotional, and problem-solving skills.

Because group fit is important, we ask that parents or caregivers complete the registration form below. This information helps us ensure the group will be a supportive and positive experience for your child.

Once you submit the form, we’ll review your responses and follow up with next steps.

Caregiver/Parent Name

First Name

Last Name

Email

Phone

(###)

###

####

Child's Name

First Name

Last Name

Child's Age

Child's School/Grade

What interests you about this group for your child?

What are your child’s strengths?

What challenges would you like your child to receive support with?

Has your child participated in therapy or groups before?

Yes

No

Is there anything else you’d like us to know about your child?

My child’s spot is not confirmed until we’ve completed the intake process and received payment.

I understand this form is for registration purposes only.