Connected Kids playgroup

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Intake Form

Your name: *

Your child's name: *

Your child's date of birth: *

Your email address: *

Your phone number: *

What are your child's strengths in peer social situations? *

What are your child's challenges in peer social situations? *

Are there any social situations that have been particularly upsetting for your child? *

What are your child's favorite toys, games, activities, etc? *

What kinds of activities do you enjoy doing with your child? *

Please feel free to share anything else you'd like us to know about you, your child, or your family. *

Consent for photos and/or video *

YES, I DO give my consent for my child to be photographed or video-recorded during group activities. I understand that these materials will be used to enhance learning opportunities for me and my child, including the creation of a take-home binder for my child. I understand that these materials WILL NOT be shared publicly.

NO, I DO NOT give my consent for my child to be photographed or video-recorded during group activities.

PLEASE REVIEW AND CONFIRM:

As facilitators, we have received specialized, discipline-specific training that equips us to address the mental health, speech/language, and sensory/motor needs of neurodivergent children.

We use a neurodiversity-affirming, play-based, and relationally-focused approach to address challenges with social navigation, self-esteem, communication, emotional regulation, inclusion, and more.

For the purposes of this playgroup, each discipline will focus on relationship development by helping your child build social-emotional skills within the context of the group. We will also provide support, guidance, and education to you, the caregivers, about neurodivergence, relational parenting, mental health, communication, etc.

We understand that each child will have different strengths and challenges, and we will tailor our therapeutic activities to meet the needs of individual children in the group. Our primary focus is on creating a caring, cohesive group – which in itself will offer robust support for the individual children within.

We are all experienced, licensed, practicing clinicians. But in the context of this group, we are not your or your child’s therapist(s). If you need recommendations for OT, speech and language, or mental health services, we are happy to provide information about local resources!

I understand the clinicians' roles within the playgroup as detailed above.

My name below serves as my digital signature, indicating that I am enrolling my child in the six-week Connected Kids playgroup. *

Please click here to submit your $300 payment via Connected Therapy LLC's Paypal account.

Connected Therapy also accepts Zelle, check, or credit card. A $9 processing fee will be added to credit card payments. For assistance with alternates form of payment, please contact: HollyOT@ConnectedTherapyRVA.com.

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