TMG Counselling Group | Registration Form

REGISTRATION FORM FOR TMG GROUPS

Bounce back K-3

Bounce back 4-8

Parent group

Parents of individuals late diagnosed with autism

GROUP NAME

PERSONAL INFORMATION

Full name of participant:

If child, date of birth:

Gender:

Pronouns:

Address:

City:

State / Province / Postal Code:

Name of therapist if seeing someone on the TMG team:

CONTACT INFORMATION

Parent / Caregiver (if applicable):

Phone number:

Email address:

Alternate phone number (optional):

EMERGENCY CONTACT INFORMATION

Emergency contact name:

Relationship to participant:

Emergency contact phone number:

ADDITIONAL INFORMATION (OPTIONAL)

Special requirements or needs (if any):

PAYMENT

All groups may be eligible under the AFU. Please identify whether you are planning on using the AFU funding

Yes

Thanks! Submission is sent.