Mission Cognition, LLC - Consultation Services Inquiry

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Hi there, thank you for your interest in working with Mission Cognition to establish, modify, or grow your behavior analytic social interaction program.

At this time, we invite you to complete the following form to give our team additional details about your needs so that we may best support you in identifying the best fit consultation package.

As a potential service provider for your business, please note that Mission Cognition, LLC is interested in gathering information about your business to accurately identify your business needs and provide quality service to you. All information provided is confidential and proprietary. We will not disclose or use your information for any reason other than to properly consult with you.

We provide consultation regarding the development, day to day operations and growth of program logistics only, and do not provide consultation regarding individual clients.

*Please note that we do not accept new consulting clients who provide services within 40 miles of current or past consulting clients. We are also not accepting any new clients in NJ, NYC, or PA at this time.

Upon receipt and review of the submitted form, we will be in touch with you within 48 hours regarding next steps which will include scheduling a complimentary discovery call as appropriate.

Warmest Regards,
Ashley & MC Consult Team

Email *

Today's Date *

Name *

Title/ Qualifications *

Company Name *

Address

Phone Number *

Email address *

*City/Town and State in which social skills services will be offered or are currently being offered *

Status of current social skills program *

in development (direct service not yet provided)

within the first few months of offering social skills groups

Established social skills program (1 year +)

If you are currently offering social skills groups, how many participants do you currently have? (total enrollment) *

If you are currently offering social skills groups, what is the age range of your participants?

Describe the population you serve or are looking to serve in social skills groups (diagnoses/level of functioning) *

In what areas are you specifically looking for guidance? Please check all that apply *

Advertising and Marketing

Intake and Assessment

Goal Development

Progress Reporting

Data Collection

Group Structure

Curriculum & Lesson Planning

Staff Training

Other:

Required

What is your preferred means of accessing consultation services (please check any/all that apply) *

phone (United States Only)

video conference

Other:

Required

I understand that this is a fee-based service. A 15 minute complimentary phone consult will be provided to gather additional information in order to identify the most appropriate consultation package to meet your needs.

yes, I understand and wish to proceed with scheduling

Other:

Clear selection

Miscellaneous Notes / Comments for the team

Submit

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