Encounter Group Screening Form

This group is for children ages 4-5 and is focused on the development of children's social and emotional skills through play-based activities. The group begins with a brief connecting activity to build rapport and establish a sense of community. From there, group members are able to play both independently and collaboratively in order to provide ways to connect with themselves and other peers.Through the medium of play, children can practice identifying and expressing their feelings, resolve conflicts with peers to increase empathy, communication, problem-solving, self-regulation, and self-awareness.

This group will be facilitated by Sarah Block, LMFT and Orion Zick, LMFTA.

The group meets in-person on Thursdays from 5pm-5:50pm from June 5th to July 31st on the following days:

June 5
June 12
June 19
June 26
[SKIP for July 4 Holiday]
July 10
July 17
July 24
July 31

The group is prepaid for $550. If you are ill or not able to attend one of the groups, unfortunately, we will not be able to provide any refund.

Optional add-in for additional parent sessions is prepaid for $75 per session (up to 2 sessions).

This is not considered a healthcare service, and is therefore NOT billable to insurance.

To apply, please fill out the form below. We will review your form to ensure your child will be a good fit for the group. Once approved we will send you a welcome letter, consent form to sign, and an invoice to finalize your registration. THIS FORM DOES NOT FINALIZE YOUR REGISTRATION!

Child's Name*

First NameLast Name

Caregiver Name*

First NameLast Name

Relationship to Child*

Caregiver Contact Email*

example@example.com

Child' Email (if applicable)

Caregiver Phone Number

Please enter a valid phone number.

Child's Date of Birth*

Date

What grade is your child in?

Which school does your child attend?

What pronouns does your child use?

What special interests does your child have?

Do you have any social, emotional or behavioral concerns for your child? If so, what are they? (Example: "my child sometimes struggles to communicate when they are frustrated")

Why are you seeking group support for your child?

What are you hoping your child gains from being involved in this group experience?

How did you hear about this group?

Other

Are you interested in round 1 or 2 of the Encounter Group?

Round 1Round 2

Is there anything else you would like us to know?

Please verify that you are human*

Thank you filling out the screening form. Once you submit the form, we will review your form to ensure your child will be a good fit for the group. Once approved, we will send you a welcome letter, consent form to sign, and an invoice to finalize your registration.

THIS FORM DOES NOT FINALIZE YOUR REGISTRATION!