T.A.L.K. Time!
Registration Form

Please take a moment to fill out the registration form, below. Your registration is not complete until we receive your initial payment of $180. After you submit the form, a page will come up with payment information.

Child's Name
Date of Birth
Parent's Name
Address
City
Zip
Home Phone
Cell Phone
E-Mail Address
(required to confirm registration)
Emergency Contact
Emergency Phone
Referred By
Diagnosis (if applicable)
Food/Environmental Allergies
Please Choose a Group
   
  Is your child currently enrolled in speech-language therapy?
 
   
  Has your child previously participated in a social skills group?
 
   
  Briefly explain some social-language goals for your child:
 
   
  Briefly describe your child's strengths:
   
I consent to treatment for my child in a 6-week, one-hour social skills group. I understand that the group will consist of a minimum of four children and a maximum of six children, plus one licensed speech-language pathologist and one adult student volunteer. I understand that payment is required in full by September 20, 2011.
 
   
 
   
   
   

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