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.

Tuition fee is $45 per week (1x group) inclusive of live zoom meetings and access to our social screens online learning portal with video lessons & practice activities targeting 12 social skills areas.

Your child must be at least 6 years old, consistently communicate in phrases/sentences, 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
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Date form filled out: *
Child's Name: *
Child's Age: *
Child's Birth Date: *
Child's Gender:
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Parent's/Guardian's Name: *
Parent's/Guardian's Email Address: *
Parent's/Guardian's Phone Number: *
State / Country *
Enrollment Status:
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Diagnosis (if any):
Classroom Placement:
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Communication: *
Independence & attention *
My child benefits from additional instruction / support in the following social/emotional/behavioral areas :
Challenging Behaviors:
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:
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How many times per week would you like your child to attend group? *
Preferred Day(s) *
Preferred Times (Eastern Standard Time)
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How did you hear about Mission Cognition?
Any additional questions or comments for our team?
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