Social Groups Application for New Clients Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastGrade? *Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Post-secondaryDate of Birth *Age *Parent's Name *FirstLastEmail *Phone Number *Sibling names and agesAddress *Address line, City, Province, Postal codeSchool Name and District/City:Date of ApplicationPreferred Location(s) *West VancouverRichmond (PAFN)Surrey* Please note that your chances of gaining a placement directly relate to your availability! If your child is home-schooled, attends college, or has a flexible schedule, please note this as it will also increase your chances of obtaining individual treatment spots that would otherwise not be filled.Preferred Days - Select All Available Days/ Locations *Mondays Tuesdays Wednesdays Thursdays * Please note increased flexibility will allow us more options to find the best fit for your child in terms of group. Please note any time restrictions on the selected days/ locations. *Does your child have an IEP? *YesNoIf your child is enrolled in a Special Education class or specific service, please list those here: *If your child receives Speech and Language services or has received them before, what is/was the frequency and duration?A. If we were to observe your child at school, please describe what we would see during: Structured time (such as classroom learning)? B. What would we see at school during: Unstructured time (such as recess/lunch):C. If we were to observe your child at home, please describe what we would see during: Structured time (such as classroom learning)? D. What would we see at home during: Unstructured time (such as recess/lunch):Brief Letter to Jenny & AssociatesPlease write a brief letter describing your child. We know your child is unique. Please provide us with a letter outlining your child’s strengths and difficulties. For example, you could include info about some or all of the following skills: -Typical interactions with peers look like… - Friendships -Self-confidence -Language capabilities -Motivation to please others -Awareness of their difficulties -Organizational skills -Being part of large or small groups -Problem solving -Manipulation (by them, or by others) -Etc. NameSubmit * Please note, we cannot guarantee the confidentiality of information transmitted through e-mail including the intake form. Please be aware of this limitation when contacting us. Share this:TwitterFacebookLike this:Like Loading...
