Early Childhood Social Skills Group (Ages 3-4)
Group runs weekly on Tuesdays 9:00 am-10:00 am and begins on June 6th 2023.  
Group is limited to 5 participants 

Please complete this secure online form in order to request you child participate in our Early Childhood Social Skills Group.. Please note that completing this form DOES NOT guarantee participation in the group.  
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What is your name? *
What is the name of your child? *
Date of birth of child *
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Phone Number *
Preferred Email *
What is the current child custody arrangement? *
Acknowledgments 

IMPORTANT: Please note that this group is currently scheduled for Tuesdays from 9:00-10:00 AM and is private pay only with a cost of $25 per child per session.  

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Required
In the event that the group is full would you like to be added to the waitlist for an opening or notified about additional availability? *
How well does your child interact with same aged peers?
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What social skills do you think your child could benefit from learning? (sharing, waiting, considering others feelings, etc.)
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Do you have any behavioral concerns for your child? If so, what are they?
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Is your child currently toilet trained? *
Patient Safety

This form is not checked 24/7. If you are having thoughts of wanting to hurt yourself or someone else, please call your local mental health support hotline, such as 1-888-796-8226 (Resolve for Allegheny County, PA), the National Suicide Prevention Lifeline 988, call 911, or go to your nearest emergency room. 

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Required

A member of our administrative team will or call or email you within 2-3 business days. When is the best time for a member of our staff to call and reach you to coordinate scheduling? 

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Preferred method of contact:

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