Social Communication Skills Class Registration

Social Skills Class Registration

Register for our 10-week, once-weekly, one-hour social skills class. Please complete the information below to help us place you in the appropriate group.
There will be four people in a group and joining is based on a first-come first-serve basis.
Would you like to be placed on a waitlist?*

YesNo
Groups cost $450 for 10 weeks and payment is due in advance of classes starting.
Select the participant's age group:*

Ages 8-10Ages 11-13Ages 14-17Ages 18-25Adults 25+
Participant's Full Name*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Diagnosis (if applicable)
Please describe any previous social skills courses, ABA therapy, or related experiences:
Select all days and times you are available to attend the weekly class (10 weeks starting June 8-12):*

Monday (Morning)Monday (Afternoon)Monday (Evening)Tuesday (Morning)Tuesday (Afternoon)Tuesday (Evening)Wednesday (Morning)Wednesday (Afternoon)Wednesday (Evening)Thursday (Morning)Thursday (Afternoon)Thursday (Evening)Friday (Morning)Friday (Afternoon)Friday (Evening)Other (please specify)
This class meets once weekly for one hour over a 10-week period, starting between June 8 and June 12. Please ensure your availability for the full duration of the course.
Where did you find out about the social skills class course?*
Parent/Adult First Name*
Parent/Adult Last Name*
Parent/Adult Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Adult Phone Number*
Please enter a valid phone number.
Parent/Adult Email Address*
example@example.com
Emergency Contact Information*
Medical Conditions or Allergies
Preferred Communication Method*

PhoneEmailText
Transportation Arrangements*

Own transportNeed assistancePublic transport
Consent for Photos or Videos*

YesNo
Special Accommodations Needed
Participant Goals
Previous Therapy or Support Services

Social Skills TrainingABA TherapySpeech TherapyOccupational TherapyCounselingOtherOther
Language Spoken at Home
Should be Empty:

Social Skills Class Registration