Social Skills Group Registration Form

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Email *

Parent/Guardian Name *

Address, City, State, Zip *

Child's First & Last Name *

Child's Date of Birth *

YYYY

Is your child currently receiving services at Project Play Therapy? If so, please indicate which services. If not, mark N/A. *

ABA

Speech

Other....

N/A

Required

Child's Age & Grade *

What would you like your child to gain from attending a social group?

Main Areas of Concern (check all that apply): *

Challenging behavior in a social setting (e.g., aggression towards peers, screaming/yelling, etc.)

Conversation skills

Making & maintaining friendships

Reading social cues & body language

Interest in playing with peers

Understanding figurative language (e.g., "keep an eye out for...", "it's raining cats and dogs", etc.)

Turn taking & sharing

Coping skills / requesting for help

Problem-solving skills

Following directions

Using appropriate/polite language with peers

Learning in a group setting (e.g., circle time learning)

Required

Other Areas of Concern

Social Group Descriptions

Social groups are divided by age. Each social group session will run for 3 days, for 1 hour per day. You may choose to sign up for more than one session for your child's age range. By registering for a social group, your child will be expected to attend all 3 days of that session.

Dates for social groups are listed below. Groups will run Tuesday, Wednesday, and Thursday for 1 hour per day at our Franklin clinic (1897 General George Patton Drive).

For all sessions, group times will be as follows:
Toddler & Pre-school: 9am-10am T, W, Th
Elementary (ages 5-7): 10:30-11:30 T, W, Th
Older kids (ages 8-13): 1-2pm T, W, Th

*Project Play reserves the right to cancel a group session prior to group starting, if registration numbers are insufficient to support a group.

Which social group session are you registering for? *

Session 1 (June 22-24) Toddler & Pre-school

Session 1 (June 22-24) Elementary-- ages 5-7

Session 1 (June 22-24) Older kids- ages 8-13

Session 2 (June 29-July 1) Toddler & Pre-school

Session 2 (June 29-July 1) Elementary-- ages 5-7

Session 2 (June 29-July 1) Older kids-- ages 8-13

Session 3 (July 6-8) Toddler & Pre-school

Session 3 (July 6-8) Elementary-- ages 5-7

Session 3 (July 6-8) Older kids-- ages 8-13

Required

Group Payment Options

Social groups may be billed in one of two ways.

1. Families may opt to use their insurance benefits to pay for social groups. This requires a verification of benefits at the time of registration (already on file for existing clients). Co-pays and other individual costs will vary based on your insurance coverage, and will be communicated to you by our client support team prior to group starting. Please be advised that using your insurance benefits for social group sessions will count toward your insurance plan's visit limit (if applicable).

2. Private pay. Families may opt to pay Project Play Therapy's private pay rate for group services. The cost of each group will be $270. Our client support team will contact you to secure a signed private pay agreement prior to group starting.

Select a group payment option *

Use my insurance benefits

Private pay

Unsure-- check my benefits and contact me

Is there any other information we should know when considering your child for a social group?

Thank you for your responses. We will be in touch with you!

A copy of your responses will be emailed to the address you provided.

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