Successfully Social Enrollment Form
So glad to have you here! Be sure to read through our enrollment policies and information FIRST (found on our website under the 'Enrollment' tab). Then please fill out this form as the next steps for securing your spot with us.
Email *
Name of Child: *
Child's D.O.B. *
Parent Name: *
Parent Phone Number *
Home Address (including zip code) *
Child's Gender *
Current school & Grade Fall of 2021 *
I am interested in *
Required
When you think of your child, what makes you feel most proud? *
What are some of your child's interest areas? *
Other important info that we should know about your child before our session. Allergies, dietary restrictions and/or other pertinent medical information. *
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?
The best day of the week for coaching is... (check all possible options) *
Required
Photos may be taken during group and shared on social media. Please indicate your privacy preference. *
Required
Name & email of person responsible for payment: *
I understand that any missed appointments will not receive a refund. *
Required
I understand that social coaching is educational in nature, not counseling or therapy and Breann is not a licensed mental health professional. *
Required
I have read the enrollment policies and information forms and understand the contents. (Please write your name and the date below. ) * *
A copy of your responses will be emailed to the address you provided.
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