Mission Cognition Pre-Registration Form
Hello! This initial interest form is the first step in the intake and enrollment process for social skills groups at Mission Cognition Social Skills Development Center. The information obtained here helps the team determine whether or not your child would be a good candidate for the program at this time. Upon receipt and review of the form, we will follow up with you to discuss your family's needs in more detail and review the next steps.
Which location are you looking to attend?
Date form filled out:
Child's Birth Date:
Parent's/Guardian's Phone #:
Parent's/Guardian's Email Address:
Town of Residence
We have NEVER been enrolled in a program at Mission Cognition
We are CURRENTLY enrolled in a program at Mission Cognition
We were PREVIOUSLY enrolled in a prior session at Mission Cognition
Diagnosis (if any):
in district self contained
In district Inclusion
In district other
In district General Education
Out of district specialized program
no formal mode of communication
alternative communication (sign, PECS, communication device)
requires consistant 1:1 support
may require 1:1 support dependent upon activity
does not require 1:1 in small group
may require minimal support to make sure all steps are done or to locate bathroom
is not toilet trained
Challenging Behaviors (please check if there is occurence in the last six months):
agression towards peers
agression towards adults
elopement (leaving area without permission/wandering off)
tantrum (screaming/flopping to floor - length of time or intensity beyond what is "typical" for child's age)
Loud vocal stereotopy
No problem behavior of this kind
Identify three (3) top priorities for skills that you would like to see addressed in social group. Please choose targets that you feel will have the most impact for your child and your family.
My child's interests include:
My child does NOT enjoy
How many times per week would you like your child to attend group?
Preferred Day (we accommodate when possible but our priority is forming best fit groups based on individual student need)
Post ESY DAY CAMP (August)
4:00 pm (weekdays only)
6:00 pm (weekdays only)
morning / afternoon (Saturday only)
Alternating Fri Teen Nights (by invite only)
Describe your child's interest in other kids/forming friendships
I am unsure
How did you hear about Mission Cognition
personal referral from currently or previously enrolled family
Any additional questions or comments for our team?
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