Successfully Social Enrollment Form
Please fill out this form as the next steps for securing a spot on the social coaching calendar.
Email *
Name of Child: *
Child's D.O.B. *
Parent Name: *
Parent Phone Number *
Home Address (including zip code) *
Gender *
Current school & Grade Fall of 2021 *
Does your child have any documented disabilities? If yes, please describe.
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
How often does your child... *
Rarely
Occasionally
Often
experience stressful situations?
have trouble concentrating?
have meltdowns?
get enough sleep?
experience digestive problems?
feel anxious, depressed, or overwhelmed?
Other important info that we should know about your child? Interest areas help too!
Name & email of person responsible for payment: *
Group Preference *
Required
I understand that any missed appointments will not receive a refund. *
Required
I understand that social coaching is not counseling or therapy and Breann is not a licensed mental health professional. *
Required
Photos may be taken during group and shared on social media. Please indicate your privacy preference. *
Required
A copy of your responses will be emailed to the address you provided.
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