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.
MM slash DD slash YYYY
Child's Name(Required)
MM slash DD slash YYYY
Child's Gender(Required)
Parent/Caregiver's Name(Required)
Classroom Placement(Required)

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)
What service/s are you interested in for your child?(Required)
Challenging Behaviors (check all that apply if occurrence were within the last 6 months)(Required)
Describe your child's interest in other kids or in forming friendships.(Required)
My preferred form of payment is – (Note: A processing fee of 3.5% will be added to credit or debit card payments.)(Required)

How did you learn about us?(Required)