TheraFriends Speech-Language Neurodivergent Peer Connections Group (4-6 year olds)

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Our groups are kid-led, joy-based & facilitated by two neurodivergent Speech-Language Pathologists, who will support each child in sharing their passions & socializing in a way that feels authentic to them.

Tuesdays in July: 7/2, 7/9, 7/16, and 7/23.
Time: 3:30pm-4:30pm
Location: Chapel Hill/Pittsboro

Group facilitators will support the development of the following skills:
*Self-advocacy
*Emotional regulation & use of regulatory tools
*Problem-solving
*Social communication
*Collaboration with peers to achieve joint goals

We ask that each family commits to a 4-week session (4 weekly group meetings) to ensure the “social” aspect of the group is maintained. This provides each client with the opportunity to authentically connect with others, allows them to have ample practice using strategies and tools, and supports the development of new skills.

Once this form is completed and submitted, you will be sent an invoice via PayPal for $260.00. After TheraFriends receives payment, you will be emailed a confirmation that your registration is complete.

Please reach out if you have any questions: email us at hello@therafriendscommunity.org; or call us at (919) 355-8194.

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PLEASE CHECK THE BOXES BELOW TO CONSENT TO YOUR CHILD'S PARTICIPATION IN A THERAFRIENDS NEURODIVERGENT GROUP.
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By checking this box, I consent for my child to participate in a group facilitated by 1-2 licensed TheraFriends Community Partnership Provider(s).

By checking this box, I understand that registration is complete once payment is received.

By checking this box, I affirm that I am the legal guardian for this child.

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Would you like information about financial assistance?

Yes. Please contact me with information.

Photo/Video Release: I grant permission for TheraFriends to use photographs/videos, including myself or my child for any of its promotional materials(e.g., brochures, newsletters, website, social media sites, grant proposals, news media, etc.) without payment or any other consideration.
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YES, I agree.

NO, I do not agree.

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Parent/Guardian Signature (typed name indicates signature)
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Caregiver Name *

Caregiver Phone Number *

Caregiver E-Mail Address *

Preferred way to receive communication from TheraFriends (check all that apply): *

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Child's Name *

Child's Birth Date *

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Child's Age *

Child's Pronouns

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Address *

Will you be utilizing NCSEEA grant funds for services?

*for more information: https://www.ncseaa.edu/

Yes

Please share your child's diagnosis or suspected diagnosis

If your child has a diagnosis, are they aware of their diagnosis?

Yes

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What are your child's greatest passions/interests?

What are your child's dislikes?

Please share any sensory support needs, accessibility needs, or triggers we should be aware of.

Does your child have any food/environmental allergies or aversions?

Are there any health/safety concerns that we should be aware of?

Does your child have any specific communication or friendship goals for themself?

What do you consider to be the main areas of support/priorities for you child

Is your child currently receiving therapy services?

Yes

No, but I would like to be contacted with more information regarding individual therapy sessions

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If yes, which therapy services are they receiving?

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