Mission Cognition VIRTUAL Social Skills Group Application
Hello! This application is for participation in ONLINE social group meetings held via a Video Conferencing platform. During the required social distancing / quarantine period, we are making this option available to current and new potential participants. Groups will meet a minimum of 1 time weekly and a maximum of 3x weekly for 30-60 min dependent upon age/target skills.

Your child must be at least 6 years old, 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 here 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.

The cost is $40 per group with a 1 time $25.00 administrative fee. A deposit of $145.00 is due to begin session once placement is formally offered and accepted. This deposit is credited toward total invoice amount. We will offer a discount for multiple groups per week.

Upon receipt of the application, we will follow up within 3 business days to advise you of the next steps. Thank you for your interest Be Kind & Be well! Ashley & Team MC
Date form filled out: *
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Child's Name: *
Child's Age: *
Child's Birth Date: *
Parent's/Guardian's Name: *
Parent's/Guardian's Email Address: *
Parent's/Guardian's Phone Number: *
State / Country *
Communication: *
Independence & attention *
My child benefits from additional instruction / support in the following social/emotional/behavioral areas :
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 *
How many times per week would you like your child to attend group? *
Preferred Day(s) *
Required
Preferred Times (Eastern Standard Time)
Clear selection
Any additional questions or comments for our team?
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