Mission Cognition YOUNG ADULT Social Group Application
Hello! This application 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 our service delivery is well matched to individual needs.
Upon receipt and review of the form, we will follow up with you to discuss your individual goals in more detail and review the next steps in the intake & assessment process.
Ashley & Team MC
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Date form filled out:
Applicant's name (Individual accessing services)
Parent/caregiver as guardian
Primary contact phone #
Primary contact email address:
What is your preferred service modality?
In person (Hillsborough, NJ)
Diagnosis (if any):
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
Types of programs (educational / social / vocational ) individual participates in
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
Challenging Behaviors (please check if there is occurence in the last six months):
aggression towards peers
aggression towards authority figure
elopement (leaving area without permission/wandering off)
Yelling / Screaming
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 the individual and those they spend most time with.
Preferred activities include:
Non preferred activities include:
How many times per week would you like to attend group?
Preferred Day (we accommodate when possible but our priority is forming best fit groups based on individual student need)
Describe interest / motivation to meet new people and form friendships
I am unsure
How did you hear about Mission Cognition
personal referral from currently or previously enrolled family
DDD/ Service Coordinator
Any additional questions or comments for our team?
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