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:
Child's Birth Date:
Parent's/Guardian's Email Address:
Parent's/Guardian's Phone Number:
State / Country
no formal mode of communication (cries, pulls, points, pushes)
alternative communication (sign, PECS, communication device)
Independence & attention
can follow along with group independently 45 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
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 Times (Eastern Standard Time)
Any additional questions or comments for our team?
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