Executive Functioning Group for Middle Schoolers

Interest Survey

Does your Middle Schooler have trouble organizing materials, regulating their emotions, setting schedules, and following through with tasks? An Executive Functioning Group is a great way to support their development in this area.

KTL is surveying families for interest in an Executive Functioning Group for Middle Schoolers ages 11-13. Participation in this group will not be billed as therapy, nor is it as intensive as therapy. Six sessions will be offered at $30/session.

Please take our survey to help us learn more about your interest in this type of group.

What day of the week are you interested in?

(You can choose more than one)

Monday

Tuesday

Wednesday

Thursday

What time works best for you?

(Choose only one)

3:00 pm

5:30 pm

Either

Name of Parent

First Name

Last Name

Name of Child

First Name

Last Name

Age of Child

(This group is for ages 11-13)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country