Social Skills Group Session Application
LEAPS Services (6 Week Session)
Applicant's Name
First Name
Last Name
Email
example@example.com
Phone Number
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
What is the best type of support that works for you (i.e. modeling, physical prompting, repeating instructions, visual, etc.)?
Do you have food allergies, or food sensitivities we should be aware of?
Are there health issues, or health concerns we should be aware of?
What are your favorite activities:
What are your least favorite activities:
Do you have fears you’d like us to be aware of? (loud noises, animals, bugs, etc.)
Do you have fears you’d like us to be aware of? (loud noises, animals, bugs, etc.)
What is your desired outcome in attending this 6 week session (i.e. make new friends, learn new things, play game, etc.?
Please select your location:
Coachella Valley
East Bay Area
Rancho Cucamonga
Orange County
Please select days of attendance:
Monday
Wednesday
Friday
Please indicate if the applicant will need a modified schedule.
6 Week Session Cost:
The cost of our session is $875 for or $50 for a drop in session. Our program is covered by the Self-Determination Program (Code-Community Integration 331). Please let us know the FMS that you are working with, so that we can send the invoice at the end of the month.
Please Select FMS:
Acumen
FMS Pay
Mains'l
Cambrian
GT Independence
Private Pay
Please provide UCI number, if payment is with SDP.
Applicant's Signature
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: