Facilitated Social Skills Group Interest Form
Group Dates: 2024 
Location: TBD
Contact us at (541) 203-0893 or connect@peakcommunicationtherapy.com

I'm so glad you're interested in enrolling your kiddo(s) in these specialized social skills groups! They're open to kiddos of all neurotypes...diagnosis or not, your kiddo is included and deserves the experience of interacting with, and learning from, other kiddos. Please complete the following form to be put on the list and help me match your kiddo with a compatible group.

I do bill insurance for social skills therapy as long as the child qualifies for services based on evaluation results. I'm currently contracted with Pacific Source Commercial. I am considered out of network with all other carriers. If I do not contract with your health insurance provider, an invoice will be provided for you to submit for reimbursement of out-of-network services. I also have a sliding fee scale for those paying out of pocket without insurance reimbursement or for those whose child does not receive a qualifying diagnosis but still needs extra support.
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Parent Name *
Email *
Phone Number *
Child's Name *
Child's Age *
What are your kiddo's learning, social, and personal strengths?  *
What are your kiddo's favorite activities and special interests? *
What skills does your kiddo struggle with (sharing, taking turns, joining play, 2-way conversations, collaborating with peers, regulating emotions and/or impulses, etc.)? *

Does your kiddo play/interact better with younger or older kiddos?

 *
Does your kiddo receive therapeutic services at school or privately? If so, please share what they're working on, diagnosis, etc. *
A communication evaluation is required to participate in the group. Have your kiddo's social communication skills been formally evaluated by a Speech-Language Pathologist within the last year? *
Which days and times generally work best for your schedule? Please list all that could apply...this will help with group placement. *
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