Katherine Schwab LMHC, PLLC

Specializing in counseling for children and their families

Activity Group Registration Form

Child’s Name:Click here to enter text.Age / Grade: Click here to enter text.

Parents’ Names: Click here to enter text.Phone Number(s):Click here to enter text.

Address / Town / Zip Code: Click here to enter text.

Email address: Click here to enter text.

Please check the best way to reach you in case of a last minute cancellation:

☐ Email☐ Phone Call☐ Text

Please use the drop down menu below to select the Activity Group you would like:

Choose an item.

Please use the drop down menu below to select the appropriate session:

Choose an item.

COST:

$175 per child for the 6 week session (includes all supplies)

$25 non-refundable deposit required to hold your child’s spot

$150 balance due at the first class

**An intake appointment is required for any new participant prior to registration in order to determine the appropriate fit for an Activity Group. The non-refundable fee for this appointment is an additional $50.

Please pay by check made out to Katherine Schwab LMHC

No refunds/credits/makeups for any missed classes.

Activity Groups are skill based and not considered group therapy; as a result they are neither billable through insurance nor bound to confidentiality expectations found in traditional counseling. Your child is able to talk to others about what happens in group, and other children may discuss what your child says outside of group. If you and/or your child want to discuss something that would best be done privately, we may decide to set up appointment to meet at a separate time outside of group (additional cost would apply).

Mail completed form with non-refundable deposit check to:

Katherine Schwab LMHC, PO Box 176, Foxboro MA 02035

You will receive a confirmation email when I have received your form and deposit.

Please sign below to acknowledge that you have read, understood, and agree to the information above.

______

Signature of parent/guardianDate

If you have questions, please contact Katherine Schwab at 508-740-0472 or

______

For Office Use:

Intake Fee Paid (if applicable)Deposit PaidBalance PaidConfirmation

Date______Date______Date______Date ______

Amount______Amount______Amount______Welcome

Check #______Check #______Check #______Date ______

Registration form and prices valid for 2017-2018 school year