Social Skills Group Registration: SPRING 2015: 4/28/- 5/19/14
Please complete this form by APRIL 22 ,2014  to save your spot. SPOTS are filling up fast.  
Registration fee of $25.00 DUE by FRI. APRIL 25 , 2014.
Make checks payable to Wakefield Consultation Services: 2507 St. Regis Court, Columbia, MO 65203.
Call 573-268-3284 if you have any questions.
Registration fee goes towards total tuition of $250.00 which is due on first session date.  
Registration fee will be fully refunded if there are not enough children who register for the group.  
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Social Skills Group will be 1 hour, 1 time per week on either Tuesdays OR Thursdays, 5:30-6:30 pm. Other time slots will be developed based on interest and availability of participants. Saturday groups can be developed if parents need that time.
Cost is $170.00 for 4 child therapy sessions, 4 parent training sessions, snacks, drinks, and materials.

Therapy will be provided by 3 certified speech-language therapists: 
Lara Wakefield, PhD, CCC-SLP
Kelly Ott, MHS, MEd, CCC-SLP
Erica Moore, MHS, CCC-SLP

Guest presenters, substitute teachers and assistants will be provided as needed, depending upon group needs.
To view more detailed information about the Social Skills Group, copy and paste the link below into your browser.
https://docs.google.com/document/d/1UKkAb1lG74GFD1ccYqcDkLhoGRmXxLnMOmlozAwXuMw/edit?usp=sharing

Child's Name *
Street Address *
City *
State *
zip code *
Date of Birth of child *
Parent/Guardian's name completing this form *
Phone number *
Relationship to Child *
Your email *
Name of person who referred you: *
Which night would you prefer to attend for Social Skills Group: Tuesdays OR Thursdays? *
Required
Does your child have an IEP *
Does your child have a 504 Plan *
Has your child had social skills group therapy in the past? *
If yes, please describe location and goals that were addressed *
What school does your child attend? *
What grade is your child in? *
Is your child: *
Please list any food allergies/sensitivities your child has: *
Please list 6 healthy snacks that your child likes: *
Please list 2 healthy drinks that your child likes: *
Please list 5 toys or games that your child enjoys playing (that are not video or computer games) *
Does your child have any of the following health/learning concerns (check all that apply): *
Required
What are the areas of concern for your child's social skills (check all that apply): *
Required
Thank you for completing this registration form. We will be in contact with you soon with more information. If you have any questions or further comments, please add them below:
Please hit SUBMIT below.  If you do not get a confirmation that your form has been sent, then scroll up to see if you omitted any info. Thanks!
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