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Confident Solutions, LLC
Mindful Thinking for Social Expectations
All classes are for elementary aged children. If you are interested in middle or high school, please e-mail us at [email protected] . I am signing up for:
Oct.8th-Nov. 12th : ________Social Learning through self-awareness (Beginning Class) $225.00 2:00-3:00
Oct. 8th-Nov. 12th : _________Zones of Regulation $225.00 3:00-4:00
Oct. 8th-Nov. 12th: _________ Practicing Social Skills $225.00 4:00-5:00
*If you have a past registration and your information is current, you only need to check which session you are signing up for and e-mail it to us. There is no need to fill out the remainder of this form again.
Today’s Date: ______________________________
Child’s Name: _______________________________ Date of Birth:____________________________
Gender:____________________________________
School: ____________________________________ Grade:_________________________________
Siblings Names & Ages: ___________________________________________________________________
Parent:____________________________________ Relationship to Child:______________________
Address:___________________________________ Cell Phone:______________________________
Email:________________________________________________________________________________
___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian
Parent:____________________________________ Relationship to Child:______________________
Address:___________________________________ Cell Phone:______________________________
Email:________________________________________________________________________________
___Guarantor ___Custodial Parent ___Non-Custodial Parent _____ Legal Guardian
Child lives with: ________________________________________________________________________Other family members (list ages)
Primary language spoken in home:_________________________________________________________
Diagnosis:_____________________________________________________________________________
Brief Description of child’s past and present services (if any):
_____________________________________________________________________________________
____________________________________________________________________________________
Brief description of current skills:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Is your child able to remain in a group setting without elopement or aggressive behaviors?
___yes ____no
Cancellation Policy: Due to prior preparation and maintaining a small class size to better serve our families, payment in full is due upon registration for the class. If Confident Solutions cancels any sessions due to inclement weather, a make-up session will be offered.
