Let's Get Started...
Social Skills Summer Camp 2019
Parent Full Name
*
First Name
Last Name
Street
*
City
*
Zip
*
Phone Number #1
*
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
E-mail
*
example@example.com
Child Name + Date of Birth
*
Full Name (Child 1)
*
mm-dd-yy (Child 1)
1
Full Name (Child 2)
2
mm-dd-yy (Child 2)
3
Full Name (Child 3)
4
mm-dd-yy (Child 3)
5
Full Name (Child 4)
6
mm-dd-yy (Child 4)
7
Full Name (Child 5)
8
mm-dd-yy (Child 5)
How Can We Help?
(Check all that apply)
*
Social Skills (Shyness, Communication etc)
Self Esteem (Body & Personal Image)
Hyperactivity (Cant Sit Still)
Concentration(Ability to stay on task, Stay Focused etc)
Depression ( Sadness, Isolation, Withdrawal)
Temper / Anger Management
Tiredness and lack of energy
Anxiety, agitation or restlesness
Trouble Thinking, concentrating, making decisions and remembering things
Angry Outburst , irritability or frustration even over small matters
Sleep Disturbances,including insomnia or sleeping too much
Death in family (hard time coping)
Divorce or separation of parents (hard time accepting)
Cant put my finger on it but my child isnt his/her self lately
Other, not listed here
Are you interested in Parenting Resources?
*
Yes, Definitely
No, Not at the Moment
No, Never
Program Details
Number of Session Visits Per Week?
*
1 / Week
2 / Week
Payment Type
*
Please Select
Cash
Credit
Insurance
Type of Insurance
*
BCBS
Etna
Medicaid
Other
N/A
if applicable
Referral?
Do you have friends or family that may be benefit from our services?
Parent 1
Phone 1
Parent 2
Phone 2
Parent 3
Phone 3
Submit
This is not a contract. All clients must be approved.
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