Social and Life Skills

Participant's Name

First NameLast Name

Date of Birth

Groups

Grades 3 - 5 (Elementary)Grades 6 - 8 (Middle School)Grades 9 -12 (High School)Young Adults (18 + 25)

Please help us to get to know your child by providing the following information. My child has difficulty:

Engaging in play or leisure activities with peersTaking turns/sharingMaintaining personal space of self or othersEngaging in activities that are not highly preferredRecognizing how his/her behavior effects othersIdentifying problems/conflictsRecognizing his/her own or other's emotionsMaking transitions between activitiesUtilizing appropriate between activities

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant's Medical Diagnosis

Attendance and Cancellation Policy

Consistent attendance and active participation in our Virtual Life and Social Skills group is a critical component to learning the skills that will be taught throughout the program. To provide the highest quality care to as many children as possible, we have created the following agreement for our families:

•Each session is 50 minutes and consists of no more than 10 participants. There is a $25 non-refundable registration fee for each applicant. If the registration fee is not paid at the time the application is submitted, your child's spot will not be reserved until the fee is paid.

•The cost of our 27-week Life and Social Skills class is $30 per week. Parents/ guardians must pay their child's weekly enrolllment fees by the Friday before their child's next group session. If a payment is returned, there will be a $25 fee, in addition to the weekly enrollment fee of $30. If enrollment fees are not paid for two consecutive weeks, your child will temporarily be placed on hold until fees are paid in full.

•A notification of 24 hours is required for a cancellation. A $30 fee will be charged after 2 late notifications of an absence. Fees for late cancellations must be paid prior to the next scheduled group session.

•We understand children get sick and unforeseen circumstances arise; however, if there are more than 3 occurrences of late cancellations or group absences, we may choose to discontinue group therapy for your child. If there is a history of late cancellations or missed appointments, services may be discontinued, and future services may not be provided.

•If an instructor cancels a group session, parents will receive a text notification of the cancellation and there will be a $15 credit placed on the participant's account to go towards the next week's session.

Our groups have a waiting list throughout the year and our goal is to place as many children as possible. To report a cancellation, please call/text LaRonda Chatman at 772-359-1267 with your child's full name and their instructor's name. Thank you!

By signing below, I understand and agree to the above policies and procedures. I authorize Destiny Therapeutic Services, LLC to bill me for rendered services.

Consent for Services

I give consent for my child/myself to participate in the Life and Social Skills group, which will be facilitated by qualified and highly experienced instructors. When I sign this consent form, I am consenting to assessments and treatment services provided by Destiny Therapeutic Services, LLC.

Date

Signature

Destiny Therapeutic Services LLC

Participant's Information

Which Life and Social Skills group would you like your child to participate in?

Parent/Guardian's Information

Medical History