Social Skills Group Sign-Up

Please complete this form to secure your spot. Reminder that in order to ensure high quality instruction, seats are limited.

Please indicate which group your child would like to attend. There is one group offered at the beginning of summer, at two different times. A second group will take place later in the summer, also available at two different times. Please specify which group and if you prefer AM or PM.

Preferred Group(Required)

Option #1: June 18 – July 23 (6/18, 6/25, 7/9, 7/16, 7/23)

Option #2: July 30 – Aug 27 (7/30, 8/6, 8/13, 8/20, 8/27)

Preferred Time(Required)

9:30 – 10:45 AM

5:15 – 6:30 PM

Parent/Guardian(s) Email(Required)

Child's Full Name(Required)

First Last

Child's Age(Required)

Please enter a number from 6 to 10.

Child's Date of Birth(Required)

Child's School(Required)

Current Grade(Required)

Parent/Guardian(s) Full Name(Required)

First Last

Contact Phone Number(Required)

Emergency Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

What do you hope your child will gain by attending this group?(Required)

Is your child participating in any current therapies at this time? (mental health, ABA, OT, Speech, etc)(Required)

Does your child receive any behavioral support in the school setting? If so, please describe.(Required)

Do you have any concerns about your child’s behavior being disruptive or unsafe in a social setting? If so, please describe.(Required)

Does your child have any medical or mental health diagnosis that would be relevant to their participation in this skills group? (toileting concerns, difficulty regulating emotions, etc)(Required)

This will NOT exclude your child from this group, but instead allow for better preparation to ensure that their needs are met.

Snacks are a great social activity and will be provided during the group. Does your child have any allergies or dietary restrictions? If so, please describe.(Required)

Do you have any concerns about your child being able to participate independently without a parent or caregiver present during the skills group?(Required)

What are your child’s preferred interests (games, toys, books?) Specific topics such as princesses, dinosaurs, nature, super heroes, etc?(Required)

Is there anything else you would like to share about your child?(Required)

How did you hear about this group?(Required)

Cost

Price:

Total

Credit Card

Card Details

Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.

Social Skills Group Sign-Up

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