Mission Cognition VIRTUAL Social Skills Group Application
Hello! This application is for participation in ONLINE social skills group meetings held via our video conferencing platform. Groups meet 1-2x weekly for 60 min dependent upon age/target skills.
The cost is $340 for 1x per week 8 week session and $560.00 for 2x per week 8 week session.
Tuition fee is inclusive of live zoom meetings and access to our social screens online learning portal with video lessons & practice activities targeting 12 social skills targets.
Your child must be at least 6 years old, communicate in phrases, be able to attend to the screen and follow along with minimal support/prompting and the absence of significant disruptive behavior to be deemed a candidate.
The information obtained below, helps the team determine whether or not your child would be a good candidate for this service delivery model, and if so, which group would be the best fit. While we take into consideration preferred days/times indicated, our priority is forming best fit groups according to age as well as areas of strength/need.
Upon receipt of the application, we will follow up within 3 business days to advise you of the next steps. We look forward to connecting with you soon!
Be Kind. Be Well.
Ms. Ashley & Team MC
Date form filled out:
Child's Birth Date:
Parent's/Guardian's Email Address:
Parent's/Guardian's Phone Number:
State / Country
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 (cries, pulls, points, pushes)
alternative communication (sign, PECS, communication device)
Independence & attention
can follow along with group independently 60 minutes
May need some additional parent prompting / modeling
Will require 1:1 support to attend and/or participate
My child benefits from additional instruction / support in the following social/emotional/behavioral areas :
Self Regulation & Managing Emotions
Non Verbal Communication
Communication / Conversation
Social Problem Solving & Conflict Resolution
Confidence & Self Esteem
Expanding Play & Leisure Skills
Group Learning Skills
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
Describe your child's interest in other kids/forming friendships:
I am unsure
How many times per week would you like your child to attend group?
Preferred Times (Eastern Standard Time)
How did you hear about Mission Cognition?
personal referral from current or previously enrolled family
Any additional questions or comments for our team?
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