Social Groups Application Form Hello. This application is the first step in the intake and enrollment process for social skills groups at Flexible Thinkers. The information obtained here helps the team determine what group will best fit your child’s needs. Upon receipt and review of the form, we will follow up with you to discuss your family’s needs in more detail and review the next steps.Today's Date(Required) MM slash DD slash YYYY Child's Name(Required) First Last Child's Date of Birth (DOB)(Required) MM slash DD slash YYYY Child's Gender(Required) male female non-binary I would rather not say Parent/Caregiver's Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Child's Diagnosis, if any(Required) What school does your child attend?(Required) Classroom Placement(Required) general education self-contained program intensive program (IP) out of district specialized program homeschool Other We will run our social skills groups after school hours on weekdays and/or between 9 AM and 2 PM on Saturdays in our center located in Purcellville. What day/s would work best for your family's schedule?(Required) Monday Tuesday Wednesday Thursday Friday Saturday What service/s are you interested in for your child?(Required) 1:1 Social Skills Development Developmental Play Group Adolescent Play Group Teens & Tweens Group I am not sure Communication(Required) no formal mode of communication alternative communication (PECS, sign language, communication device, etc.) single words phrases sentences Independence(Required) requires constant 1:1 support may require 1:1 support, depending on the activity does not require 1:1 in small group Toileting(Required) 100% independent may require minimal support to make sure all steps are done or to locate bathroom not toilet trained Challenging Behaviors (check all that apply if occurrence were within the last 6 months)(Required) self-injury aggression towards peers aggression towards adults elopement (leaving area without permission/wandering off) tantrum (screaming, flopping to floor – length or intensity beyond what is considered ‘typical’ for child’s age) foul language loud vocal stereotypy no problem behavior of this kind Identify three (3) top priorities for skills that you would like to see addressed in social group. Please choose targets that you think will have the most impact for your child and your family.(Required)My child's interests include:(Required)My child does NOT enjoy:(Required)Describe your child's interest in other kids or in forming friendships.(Required) I am not sure Very resistant Seems disinterested Interested Very interested Any comments, questions, or concerns?My preferred form of payment is – (Note: A processing fee of 3.5% will be added to credit or debit card payments.)(Required) Credit card Debit card Personal check Money order Cashier’s check Other How did you learn about us?(Required) Social Media (Facebook, Instagram) Google Search Personal Referral School Personnel Community Event Medical Provider Flyer/brochure/leaflet from a local business Other CAPTCHA