Growing Minds
Distance Training Registration Form


Mother’s Name:
Father’s Name:
Mailing Address:
ZIP / Postal Code:
Email Address:

 * Required Field Please enter your full email address
Child lives with: Both parents   Mother    Father
Other: (please explain)
Please indicate your relationship to the child: Mother    Father    Other: (please describe)
Child’s Full Name:
Date of Birth:   Gender:   Female     Male
Language spoken at home:
Child’s Height:   Child’s Weight:
Give a brief description of your child's current development in terms of...
Fine Motor:
Gross Motor:
Social Skills:
Self Help Skills:
Does your child attend school? Yes     No    
If yes, please indicate how many hours per week, what type of school / class, number of students in the class, etc. Do you intend to keep your child in this program while doing Growing Minds? 
Does your child have any medical conditions or physical limitations that we should be aware of?
Yes   No      If yes, please explain fully.
Is your child currently on medication? Yes   No      If yes, please explain fully.
What about being with your child do you enjoy most?
What do you find most difficult about your being with your child?
What are your goals for this training?
Is there any additional information you believe would be useful for us to know?

Cancelation Policy

If you cancel a distance program: Prior to beginning the program, you’ll receive a refund, less a $250 administrative fee. In addition, the cost of any bank or credit card charges incurred for receiving and refunding your payment will be subtracted from the refund. After receiving your assessment, no refunds will be given.

If you miss a video review: The distance program includes one video review session. This is usually done in the middle of your 6-month program. If you don’t send us a video in time for the scheduled session (or contact us by the video due date to make other arrangements) we will provide the scheduled phone session as a consultation without the video review portion.

Taking “time off” from the distance program/postponing sessions:
We strongly encourage you to complete your 12 phone sessions within the scheduled 6-month period. However, you may extend your program for up to seven months.

The 6-month distance program may not be extended for longer than seven months. Sessions not used within seven months after your first phone session will be forfeited. Exceptions will be made for serious family illness. Please understand that this policy is necessary because we have a waiting list of families for the distance program.

If you miss or cancel scheduled phone sessions:
We require three business days’ notice for session cancellation, for a maximum of 2 cancellations within the 6-month program. With this notice, we will re-schedule your session, at our earliest opportunity, regardless of your reason for canceling.

Missed sessions and sessions cancelled with under 3 days’ notice will not be re-scheduled. After 2 cancellations in any 6-month program (even with sufficient notice), further cancelled sessions will not be re-scheduled. Exceptions will be made for serious family illness.

Registration Downpayment

Payment: A deposit of $500 is due upon registering. A second payment of $2,700 is due prior to your evaluation. Fees can be paid by check or credit card (Visa or MasterCard). Checks from outside the US must be international money order or cashiers check payable in US currency only.

I am sending you a check or money order for $500. (Payable in US funds).

Please charge the $500 deposit to my: MasterCard   Visa
Credit Card Number: 
Expiration Date:  (month/year: 00/00)