Encounter Group Questionnaire

The group is focused on the development of children's social and emotional skills through play-based activities. The group begins with a brief check-in and song to build rapport and establish a sense of community. From there, the children are given the raw materials for play such as clay, music, storytelling, and collage to provide ways to connect with themselves and the rest of the group. 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. We end each group with a song and "check-out", to see if there are any lingering hurts or feelings to process, and to say goodbye.

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

The group meets in-person on Fridays from 10:00-11:00am on the following days:

June 23rd
June 30th
July 7th
July 14th

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

Is there anything else you would like us to know?

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!