Successfully Social New England Enrollment Form
Yay glad to have you here!
FIRST be sure to read through our enrollment packet that has all the details about our groups on our website under the 'Enrollment' tab.
SECOND please fill out this form as the next steps for securing your spot with us.
Thank you!

Questions?
Please email Allison at SuccessfullySocialNE@gmail.com

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Email *
Name of Child: *
Child's D.O.B. *
MM
/
DD
/
YYYY
Parent Name: *
Parent Phone Number *
How did you hear of us or who can we thank for referring you to us? *
Home Address (including zip code) *
Gender *
School & Grade Fall of 2022 (if applicable) *
Services I am interested in *
Required
Please confirm that you understand the following *
Required
Which do you prefer? *
When you think of your child, what makes you most proud? *
What are some of your child's interest areas? *
Does your child have any documented disabilities? If yes, please describe.
Other important info that we should know about your child before our session. Allergies, dietary restrictions and/or other pertinent medical information. *
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?
Photos may be taken during group and shared on social media. Please indicate your privacy preference. *
Name & email of person responsible for payment: *
I understand that any missed appointments will not receive a refund. *
Required
I understand that social coaching is educational in nature, not counseling or therapy and Allison is not a licensed mental health professional. *
I have read the enrollment policy packet on the website, understand and agree on pricing and policies. (If so, please write your name and the date below.) *
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