Radically Resilient Kids Series
A creative approach to improving executive functioning and social emotional learning.
Each session is 5 weeks and includes a weekly virtual 1 hour ‘Community Meeting’ via Zoom.
$300 for 5 weeks.

Questions?
Please email
Allison at SuccessfullySocialNE@gmail.com
or
Breann at breann@successfullysocialco.com
Email address *
Name of Child: *
Your answer
Child's D.O.B. *
MM
/
DD
/
YYYY
Parent Name: *
Your answer
Parent Phone Number *
Your answer
Home Address (including zip code) *
Your answer
What time zone are you in? *
Enroll us in... (groups are held on Tuesdays, Wednesdays or Thursdays- one hour per week, for 5 weeks) *
Required
Gender *
Current school & Grade Fall of 2020 (if applicable) *
Your answer
Does your child have any documented learning disabilities? If yes, please describe.
Your answer
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
Other important info that we should know about your child before group: *
Your answer
Additional email for parent wrap up email?
Your answer
Name & email of person responsible for payment: *
Your answer
Full payment ($300) for all 5 weeks is due before group. Invoice for payment will be sent after registration is received- Venmo or Paypal accepted. Thank you! *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy