Successfully Social New England Intake Form 2024
Yay glad to have you here! 

Be sure to read through our enrollment & policies packet then please fill out this form to let me know you are interested in services.  

Group Coaching $75/hour
Individual Coaching $150/hour

Thank you!

More info at BeSuccessfullySocial.com 

Questions?
Please email Allison at Allison@BeSuccessfullySocial.com

Mailadresse *
Do you give us permission to add your email to the Successfully Social Mailing list *
Name of Child: *
Nickname or other name child goes by
Child's D.O.B. *
DD
/
MM
/
ÅÅÅÅ
Child's Current Age *
Parent Name: *
Parent Phone Number *
How did you hear of us or who can we thank for referring you to us? *
Home Address (including zip code) *
Gender *
School & Grade 2023-24 (if applicable)
Services I am interested in (check all that apply). Please note that we do not accept Health Insurance.  *
Påkrævet
Please confirm that you understand the following *
Påkrævet
I do the best I can to accommodate schedules. Please let me know the days you are AVAILABLE for group. *
Påkrævet
When you think of your child, what makes you most proud? *
What are some of your child's interest areas? *
In your opinion what is your child currently struggling with or what made you want to reach out? *
Does your child have any documented diagnosis and/or a disability that would be helpful for us to be aware of?
Other important info that we should know about your child before our session. Allergies, dietary restrictions and/or other pertinent medical information. *
We would love to get to know your child more. Please rate your child using our 1-5 scale, with 1 being the worst and 5 BEING THE BEST. *
1 Worst
2
3
4
5 Best
Paying attention to others
Asking about others
Showing empathy
Taking responsibility for self
Understanding consequences
Understanding the feelings of others
Accurately identifying body language
Accurately identifying facial expressions
Understanding what people mean by what they say
Asking for help
Greeting others
Personal problem solving
Participating in a conversation
Compromising and/or negotiating
Adding relevant comments to a conversation
How often does your child... *
Rarely
Occasionally
Often
experience stressful situations?
have trouble concentrating?
have meltdowns?
get enough sleep?
experience digestive problems?
feel anxious, depressed or overwhelmed?
Photos may be taken during group and shared on social media. Please indicate your privacy preference. *
Name & email of person responsible for payment:
Please note that we cannot accept insurance however, we will provide a detailed receipts for services. 
 *
I understand that any missed appointments will not receive a refund. *
Påkrævet
I understand that social coaching is educational in nature, not counseling or therapy and Allison is not a licensed mental health professional. *
I have read the enrollment policy packet on the website and agree on pricing and policies. If so, please write your name and the date below. *
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