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About Us
2025 Summer Programs
Summer Enrichment 2025
Student Services
Educational Therapy
Executive Functioning Support
Test Prep
Social Skills Sessions
Baby Brain Boost
Speech and Language
Occupational Therapy
Parent Support
ADHD Support Group
Parent Coaching
Observation/IEP Meetings /Advocacy
School Support
Workshops
Team
Contact
Important Forms
Home
About Us
2025 Summer Programs
Summer Enrichment 2025
Student Services
Educational Therapy
Executive Functioning Support
Test Prep
Social Skills Sessions
Baby Brain Boost
Speech and Language
Occupational Therapy
Parent Support
ADHD Support Group
Parent Coaching
Observation/IEP Meetings /Advocacy
School Support
Workshops
Team
Contact
Important Forms
Social Skills Registration Form
Please complete the form below
Name
*
First Name
Last Name
Age
Date of Birth
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender
Male
Female
Parent/Guardian Name
Daytime Phone
(###)
###
####
Mobile Phone
(###)
###
####
Email
*
Please specify allergies (if any)
Please check all the concerns that apply regarding your child and indicate degree of concern. All information you provide is held in strict confidence.
Adjusting to divorce/separation
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Aggressive Behavior
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Anxiety
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Conduct
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Discipline
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Family communication
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Identity concern
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Interpreting social cues
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Organization
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Conversation turn taking
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Understanding facial expression
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Making eye contact
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Appetite disturbance
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Depression
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Distractibility/attention
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Hyperactivity
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Impulse control
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Motivation
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Panic attack
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Joining a group
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Please share any additional questions, comments, or concerns.
Thank you!
