SLC Social Group Registration Form

Thank you for your interest in our social cognitive groups. Fall registration for the 2019 semester is now CLOSED. Please complete the form below and someone from our office will be in touch. If you are a new client to the SLC please click here for our intake form for new clients. Please keep in mind all intakes for a social groups are $150 and will be expected at the time of your visit.

Rate: TBD for Winter 2020

Groups are slated to start the week of _____________. Registration will close on ______________.

Please remember intakes for our SLC Groups are NOT covered by insurance and are $150 at the time of your visit.

Please complete the form below

Client Name *
Client Name
Client status *
Please indicate if you are a returning client or new client. Please remember all new clients will be scheduled for an in take before accepted into a group.
Phone Number
Phone Number
Please let us know the DOB, Age and grade of the participant.
Type of group *
Please indicate the type of group you/your son/daughter are interested in joining.
Please indicate the best days/times for you/your child to attend group.
Please give a brief description of you/your son/daughter's reason for wanting to be in a social group and any relevant history.
Please know that by completing this form you are liable for a $65 deposit to hold your space in the group. If you consent, please indicate "$65" in the field below and our office will be in touch to arrange payment.