Young Adult Social Group
Thank you for applying for our Young Adult Social Group. Once you have submitted the following information, our group leader, Emily McCollam,M.C.D., CCC-SLP will contact you to complete your registration. Deadline to register is two weeks prior to the first day of the club.
Todays date
*
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Month
-
Day
Year
Date
How did you hear about this group?
*
Group Member's Information
Group Member's Name
*
Group Member's First Name
Group Member's Last Name
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Gender
*
Female
Male
Has your child received services from DTS in the past?
*
Yes
No
Name of Current School and/or Activities
*
Days and hours of attendance at current school and/or activities?
*
What is your child's availablity for the social group?
*
Language(s) spoken and understood at home.
Please share any specific diagnoses given.
*
Any medical conditions we should be aware of while your child is under our care?
*
Does your child have any allergies?
*
Yes
No
Anything else you want to tell us?
Primary Caregiver's Information
Full Name (Primary Caregiver)
*
Primary Caregiver's First Name
Last Name
Relationship to Group Member
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact in case we cannot reach parent:
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First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Social Group Information
What is your reason for joining this group?
*
Has your child attended a social group before?
*
Yes
No
What was the name, location, and purpose of the prior social group?
Has your child received individual speech therapy before?
*
Yes
No
Please tell us about your child's previous speech therapy.
What are your child’s specific interests or hobbies that they might want to share with the group?
*
Is there anything specific you would like your child to gain from this social group?
*
Please describe your child’s personality. Check all that apply.
*
My child is very talkative but only with people he/she knows
My child is extraverted and likes to talk to anyone around
My child is very shy most of the time
My child tends to be reserved in new situations, but later becomes outgoing
My child is slow to build trust with unfamiliar people
My child shows a lot of interest in same-age peers and actively tries to engage with them (whether successfully or not)
My child shows some degree of interest in same-age peers but only sometimes or rarely attempts to engage with them
My child does not show interest in peers
Other
Thank you!
We will contact you shortly to complete your child's registration.
Submit
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