Summer Social Experience 2022
Woohoo happy to have you here!
Please fill out this Summer Social Experience 2022 form to request a spot for your child.

Questions?
Please email
Allison at SuccessfullySocialNE@gmail.com

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Email *
Please be aware that submitting your application does not guarantee placement. Group placement is primarily based on matching similar clients for the best possible learning environment and group interactions. It will also depend on client availability. You will receive a 'Social Group Offer' form when there is a group available. *
Name of Child: *
Child's current age *
Child's D.O.B. *
MM
/
DD
/
YYYY
Parent Name: *
Grade and School attending in the Fall of 2022 *
Signing my child up for *
Required
Parent Phone Number *
Home Address (including zip code) *
Gender *
School & Grade Fall of 2022 (if applicable) *
Does your child have any documented learning disabilities? If yes, please describe.
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?
Other important info that we should know about your child before group. Interest areas help too! *
Name & email of person responsible for payment: *
I read all the details and FAQs *
Required
Photos may be taken during group and shared on social media. Please indicate your privacy preference. *
I understand that social coaching is educational in nature, not counseling or therapy and Allison is not a licensed mental health professional. *
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