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Feb 2024. Dating Social Skills Intake Form (Feb 6-Feb 27)
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Email
*
Your email
Name of Participant
*
Your answer
Age of Participant
Your answer
School District or Adult Program Participant Attends
Your answer
Is the participant willing to participate in group?
Yes
Participant is resistant but will actively participate
Resistant but these are important skills that the participant must learn
No
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Name of Parent
Your answer
Parent Phone Number
Your answer
How did you hear about this Group?
Your answer
Any other important information for Deirdre to know about the participant?
Your answer
Payment: Venmo (@Deirdre-Flores-SLP). Payment of $270 to secure spot
I agree to payment policy
Other:
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