Simply Social: Services Interest Form
To obtain additional information about Simply Social offered classes, please complete the form below and submit it. We will contact you within 3 business days.
Teen or Adult Participant Full Name *
Your answer
Parent First and Last Name (if under 18 years)
Your answer
Phone Number (where you can most easily be reached) *
Your answer
Best time to contact you (Days and times where you can most easily be reached) *
Your answer
Address/City *
Your answer
E-Mail Address *
Your answer
Age of Adolescent, Teen, or Adult *
Your answer
Do you work with a Michigan Rehabilitation Services (MRS) office, or were you referred by MRS? *
If you answered "yes" to the question above that you do work with MRS, please indicate the MRS counselor name.
Your answer
If you are an MRS representative, please provide your name below.
Your answer
What type of training are you interested in? *
Required
If you selected "other" type of training, please specify what type of support you are seeking
Your answer
Do you, or your child (if you are the parent/guardian), have a medical diagnosis for a disability (note that a school eligibility for special education services is not a medical diagnosis).
What was the diagnosed disability or disabilities if one or more were given?
Your answer
If a medical diagnosis was completed, please specify where it was done. For example by an Authorized Autism Evaluation Center/AAEC, a physician, a psychologist, a psychiatrist, a medical center, a university, etc.) Note that a school eligibility for special education services is not a medical diagnosis.
Your answer
Does the teen, or adult have an IEP or 504 at school?
If the teen, or adult DOES have an IEP, what is the special educational eligibility (for example autism, cognitive impairment, developmental delay, emotional impairment, or other). Answer unknown if not known.
Your answer
What times of day/evening are best for you to attend the social skills group? (check all that apply) *
Required
How were you referred to Simply Social, LLC (please be as specific as possible). *
Your answer
Please provide any additional information you feel would be helpful.
Your answer
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