Summer Social Pre-Registration / Interest Form for JC

Hello!
This initial interest form is the first step in the intake and enrollment process for social skills groups by Mission Cognition Social Skills Development Center hosted at Speech Quest , Jersey City (581 Jersey Ave)

Groups will meet July & August on Tuesdays and/or Thursdays at Speech Quest (1x per week group but you may register for both days if interested)

The information obtained here helps the team determine whether or not your child would be a good candidate for the program at this time. Upon receipt and review of the form, we will follow up with you to discuss your family's needs in more detail and review the next steps.

We look forward to speaking with you!

For immediate questions you may
Call:
908-359-0014 (Mission Cognition)
201-381-1607 (Speech Quest)

Email:
Info@missioncognition.com
SpeechQuestJCNY@gmail.com

Date form filled out: *
MM
/
DD
/
YYYY
Child's Name: *
Your answer
Child's Age: *
Your answer
Child's Gender: *
Child's Birth Date: *
Your answer
Parent's/Guardian's Name: *
Your answer
Parent's/Guardian's Phone #: *
Your answer
Parent's/Guardian's Email Address: *
Your answer
Classroom Placement
Communication: *
Independence: *
Toileting: *
Challenging Behaviors (please check if there is occurence in the last six months): *
My child's interests include:
Your answer
My child does NOT enjoy
Your answer
How many times per week would you like your child to attend group? *
Preferred Day (we accommodate when possible but our priority is forming best fit groups based on individual student need)
Describe your child's interest in other kids/playing together/forming friendships *
Very Resistant
Very Interested
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.
Your answer
I feel my child would benefit from additional supports to
Any additional questions or comments for our team?
Your answer
Submit
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