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Prism: ACT Social Skills Group Sign Up/Interest Form
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Email
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Record my email address with my response
Name or Initials of Learner:
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Name of Guardian:
Your answer
Email Address:
Your answer
Are you a current client?
Yes
No
Clear selection
If no, does the learner have an ASD diagnosis?
Yes
No
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Which group does the learner fall into?
5 - 8th grade
9 - 12th grade + young adults
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Which day(s) of the week would they be able to attend a telehealth ACT group?
Monday
Tuesday
Wednesday
Thursday
Friday
Additional questions or notes:
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