Fall 2022 Second Session New Enrollment

A $50 deposit is now required to reserve a spot for your child in the upcoming schedule. After submission, we will reach out to you with recommendations for a class and a time slot for your child.

Fall Session 2: October 17-December 2, 2022 (Off November 21-25) – 6 weeks $465 2.5-3.5 year olds/PREK-5th/ Middle School/High School $395

Child's Information

Child's Name*

Date of Birth:*

Current Grade/School

Address*

Separator

Parent 1 Information

Parent 1 Name*

Parent 1 Phone*

Parent 1 Email*

Best time to call

Parent 2 Information

Parent 2 Name

Parent 2 Phone

Parent 2 Email

Best time to call

Emergency Contact Information

Emergency Contact Name*

Emergency Contact Phone*

Relationship to Child*

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Child's Medical Information

Allergies (Please List)

Referred by

Providers we are currently working with

Current Medications/dosage/frequency

Current Diagnosis and or medical condition(s)

(Continued)

My child does not have a current diagnosis and/or medical condition

Child's Behavioral Information

Likes*

Dislikes*

My child needs support with:

Social behaviors ( personal space/greetings/goodbyes)

Conversational skills

Making/keeping friends and getting along (social rules/initiating/problem solving)

Emotional Regulation (labeling emotions/understanding emotions of him/herself and those of others/relaxation techniques during times of frustration or times of stress)

Other:

Please specify:

Concerns/Behaviors noted at home and or school*

Your Goals for Group

Payment Details

Single Class Registration Deposit*

A deposit is required upon registration to guarantee you a spot in the upcoming class schedule. This amount is put toward the total payment for the classes.

Total $ 50

Credit/Debit Card