MJ Kidz Groups Interest Survey
Share your contact info and preferences to help us gauge interest in new private-pay skills groups (not billed through insurance).
Parent/Guardian Name
*
Best Email to Reach You
*
example@example.com
Best Phone Number to Reach You
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Name
*
Child's Age
*
Which MJ Kidz location do you currently visit or live closest to?
*
Please Select
Marlton
Swedesboro
Collingswood
Not currently a client
Are you currently a patient of MJ Kidz?
*
Yes
No
Which group type(s) would interest you?
*
Social Skills
Executive Functioning/Organization
AAC/Communication Support
Feeding-Based Group
General themed-group for my child's interest (e.g. legos, crafts etc.)
Not sure - open to recommendation
Which specific skills would you like your child to work on? (Select all that apply)
*
Starting and keeping a conversation going
Taking turns / listening to others
Reading body language & social cues
Making and keeping friends
Sharing & playing cooperatively
Handling teasing, conflict, or disagreements
Emotional regulation (managing big feelings, frustration, meltdowns)
Understanding others' perspectives/empathy
Not sure - open to recommendation
Which specific skills would you like your child to work on? (Select all that apply)
*
Following multi-step directions
Organization & planning
Time management
Flexible thinking / problem-solving when things change
Impulse control
Starting tasks (not just finishing them)
Working memory (holding onto instructions/info)
Self-monitoring / checking own work
Not sure - open to recommendation
Session length preference
30 minutes (around $30)
45 minutes (around $40)
60 minutes (around $50)
No preference
Other
Given the out-of-pocket cost range of $30–$50 per session, how comfortable are you moving forward?
Comfortable with this cost
Depends on exact price and length
Not able to at this time
Other
Series length preference
4 consecutive weeks
6 consecutive weeks
8 consecutive weeks
No preference
Other
Which days of the week work for your family? More availability = more group options for your child.
Monday
Tuesday
Wednesday
Thursday
Saturday
Which time blocks work best? More availability = more group options for your child.
Morning: 9-12pm
Early Afternoon: 12:30-3pm
3-4pm
4-5pm
5-6pm
6-7pm
Other
What are your child's favorite interests or themes that would motivate them to join a group?
Legos
Minecraft
Pokemon
Art & Crafts
Disney
Music
Dolls/Stuffed Animals
Sports
Animals
Dinosaurs
Superheroes/Video Games
Character Themed (e.g. Bluey, Mickey etc.)
Other
Anything else we should know?
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