Peers Play Services Inquiry Form

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Thank you for your inquiry into social groups and consultation services. By filling out this inquiry form, you are sharing information with us confidentially to determine whether our social groups may be a good fit for your child. Filling out this form IS NOT a commitment for services on your behalf or ours.

Once the form is received, please allow 2 weeks for us contact you. In the event that we cannot fit your child into a group at this time, we will let you know and reach out if we have availability.

Email *

Please confirm you email *

Parent / Guardian Names (First, Last) *

Phone Number *

Child's Name (First, Last) *

Child's Age *

Child's Date of Birth *

YYYY

Does your child have a relevant diagnosis?

What school does your child attend (if any)?

Grade current school year

Preschool

Pre/K

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Sixth Grade

Other:

Clear selection

Please select any supports you are interested in. *

Social Skills Group (3-5 year olds)

Social Skills Groups (Kindergarten-1st grade)

Social Skills Groups (2nd grade)

Social Skills Groups (Girls Groups for 2nd-4th graders)

Social Skills Groups (Girls Groups for 5th-6th graders)

Parent Coaching

School Consultation and Support

Other:

Required

What concerns bring you to seek services? *

Has your child received other interventions already? (i.e. ABA, OT, Speech, PT) Please provide a brief overview. *

What medical insurance provider do you use? Please note we do not bill insurance directly. *

How did you hear about Peers Play? *

Parent/Caregiver network

School recommendation

Other professional recommendation

Internet Search

Other:

Required

If you are interested in a social group, what days / times is your child available for social groups?

Monday

Tuesday

Wednesday

Thursday

Friday

11:00-12:15 pm

1:45-3:00 pm

3:30-4:45 pm

4:15-5:30 pm (2nd-6th grade girls only)

5:30-6:45 pm (2nd-6th grade girls only)

Anything else you would like us to know about your child?

Send me a copy of my responses.

Submit

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