Application Form for 2020 Summer Intensive Social Communication Program at Speech and Hearing Associates

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Email *

Child's Name *

Nickname

Date of Birth *

YYYY

Parents' Name(s) *

Parent Daytime Telephone *

Parent Alternate Telephone

Address *

Parent Email *

Emergency Contact Name and Phone Number *

Does your child currently have, or has your child ever had, any therapy services such as PT, OT, or ST in school or through Early Intervention or another provider? *

Yes

If yes, please describe:

Does your child have allergies? *

Yes

If yes, please list them:

What do you want your child to gain from participation in this program? (Check all that apply) *

Increase vocabulary

Better ability to respond to questions

Improve following directions

Enjoy peer interactions

Have fun

Be able to tell a story

Other

Other:

Required

If other, please describe:

Which location would you like to attend the program in? *

Westfield

Metuchen

Program Details

The 10-day summer program will be held Monday to Friday, August 17th through August 28th at Speech and Hearing Associates' Westfield and Metuchen locations.

The program will consist of small groups of no more than five to six children participating in sessions with a certified, licensed, speech-language pathologist. The focus of the sessions will vary based on group needs however there will be a specific area of focus for each child based on the child’s most significant areas of social/pragmatic weakness.

In addition to learning social/pragmatic language skills in a structured intervention, participants will then have the opportunity to use their skills as they participate in community-based activities. These activities will include group outings such as parks, ice cream parlors, and child friendly play environments during which time they will be encouraged to utilize social/pragmatic skills with their peers. Parents are present for all community based activities and are encouraged to participate and use clinician guided strategies and techniques to encourage appropriate social interactions.

To get started, the child and parent will have a one-hour initial consultation with a speech-language pathologist to determine group placement and individual goals.

The total fee for the 10-day 15.5 hour summer program including activity fees is $61.30 an hour. Due to the highly social and recreational nature of this program, it is not eligible for coverage through insurance. Participants are expected to attend the entire program, all 15.5 hours. The fee will not be prorated for missed sessions.

There is an application fee of $150 required at time of application. This will be applied to the total tuition cost. The application fee is not refundable.

The fees are payable as follows:
1. Application fee of $150 before initial consultation
2. 1/2 of fee ($400) due 1 week before the program starts
3. Balance of fee ($400) due at first session

There are no partial refunds. The commitment is for the full two weeks and there will not be a refund for any missed sessions.

The deadline for enrollment is Monday, July 27th.

Applications will not be reviewed until the application fee of $150 has been received.

Payment Information *

I will mail a check to Speech and Hearing Associates at 121 South Euclid Ave, Westfield, NJ 07090

Please call me to obtain my credit card information

Send me a copy of my responses.

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