Children's Storytime Hour Group Questionnaire

The Children's Storytime Hour Group lead by our newest team member Adora Du is for children ages 5-7. There are many beautiful lessons - and artwork - embedded in children's stories! Each week this group will read a book that addresses a social emotional topic such as self-awareness, mindfulness, and collaboration. From there they will discuss the takeaways of the story. The kiddos will then engage in an art activity using the theme of the book of the week to process their thoughts and emotions.

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 Wednesdays from 5:00pm-6:00pm on the following days:

Oct 4th
Oct 11th
Oct 18th
Oct 25th
Nov 1st

The group is a prepaid service for $40. 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!

Children's Storytime Hour Questionnaire