SLC Social Group Intake Form

Thank you for your interest in our social groups. Please complete the form below and someone from our office will be in touch to schedule your visit. Please keep in mind all intakes for a social group are $150 and will be expected at the time of your visit.

Please complete the form below

Client Name *
Client Name
Parent
Parent
Address
Address
Phone Number
Phone Number
Please let us know the DOB, Age and grade of the participant.
Please give a brief description of you/your son/daughter's reason for wanting to be in a social group and any relevant history.