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.

Warmly,
Ashley & Team MC

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Date form filled out: *
MM
/
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Applicant's name (Individual accessing services) *
Age: *
Guardianship *
Required
Primary contact phone # *
Primary contact email address: *
What is your preferred service modality? *
Diagnosis (if any):
Town of Residence *
Enrollment Status *
Types of programs (educational / social / vocational ) individual participates in *
Communication: *
Independence: *
Challenging Behaviors (please check if there is occurence in the last six months): *
Required
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) *
Required
Preferred Time *
Required
Describe interest / motivation to meet new people and form friendships *
How did you hear about Mission Cognition *
Required
Any additional questions or comments for our team?
Submit
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