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Confident Solutions, LLC 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:
Jan. 28th-March 4th : This class is full Social Communication $225.00 1:00-2:00
Jan. 28th-March 4th: _________Mindful Thinking & Zones of Regulation $225.00 1:00-2:00
Jan. 28th-March 4th: _________Self-Awareness-Learning How to “Think” About Thinking Socially $225.00 3:00-4:00
Jan. 28th-March 4th:__________Self-Awareness-Learning How to “Think” About Thinking Socially $225.00 4:30-5:30
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.
