Social Skills Group Registration

    Pick a Session:
    Pick a Group:

    Group pairings are made based on skill level, with a general consideration for age level as well. You will be contacted after registering to set up your screening.

    Child Information

    Child’s Name:

    DOB:

    Age:

    Grade:

    Parent Information

    Parent’s name:

    Address:

    Phone:

    Email:

    QUESTIONNAIRE

    1. Does your child have a medical diagnosis? Allergies? Is he/she taking any medication?

    2. Please describe how your child relates to other children. Do they initiate play with others?

    3. Please explain what your goals are for your child during group therapy.

    4. Does your child get easily overwhelmed? If so, please explain.

    5. What activities hold your child’s attention the longest?

    6. What activities hold your child’s attention the least amount of time?

    7. Does your child avoid any play activities?

    8. Has your child ever received Speech therapy or group services? If so, with whom and for how long?

    9. How would you describe your child? (i.e. Overactive, shy, friendly, defiant, etc.)

    10. How does your child respond to facial expressions? For example, can he/she tell you are upset by just looking at your face?

    11. Is your child competitive? Please explain.

    12. How does your child respond to compromise and verbal discussions?

    13. How does your child respond to sudden changes in environment or schedule?

    14. Is your child able to problem solve when something unexpected happens? Please explain.

    15. Anything else we should know?

    Photo Release

    I give permission to Little Hands Pediatric Therapy to use my or my child’s photograph publically to promote the Little Hands Pediatric Therapy. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use. (required to check one)
    AgreeI do not give permission

    Makeup and Refund Policy

    I understand that no make ups will be provided for classes missed. I understand that Social Skills Groups are classes and not group therapy, therefore I will not be provided with a superbill for insurance reimbursement. I understand that there will be no refunds after October 31st, except under the following conditions: my child is not offered placement in a social skills group or if that group does not have a minimum of two children.

    INDEMNIFICATION AND WAIVER

    I hereby assume all risk and agree to accept full responsibility and liability for any damages or injuries I or my dependent may cause or suffer arising out of participation in the above-referenced activity or event sponsored by Little Hands Speech Therapy, including any such damages or injuries occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangements or transportation which may be provided for or as a part of the activity or event.

    I hereby agree to be fully liable for and hereby agree to waive and release Little Hands Speech Therapy, its employees and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which I or my dependent may sustain or cause as a result of my participation in the above-referenced activity or event sponsored by Little Hands Speech Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the event or any travel arrangement or transportation provided as a part of the activity or event.

    I further agree to indemnify, reimburse, and forever hold harmless Little Hands Speech Therapy its employees, and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which I or my dependent may sustain or cause as a result of participation in this activity or event sponsored by Little Hands Speech Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangement or transportation provided as a part of this activity or event.

    I am aware of the risks associated with participation in this activity or event and hereby accept and assume on behalf of myself or dependent full responsibility for any and all such risks, including, without limitation, the need to check with a physician before engaging in this activity or event, including any physical activity associated with this activity or event.

    I further agree that my own or dependent’s own personal health insurance with or membership in shall be the primary source of health insurance coverage in the event that I or my dependent sustain an injury while participating in this activity or event sponsored by Little Hands Speech Therapy.

    I acknowledge that I have read and voluntarily agree to the terms of this Indemnification and Waiver. If any portion of this Indemnification and Waiver shall be held invalid for any reason under the laws of the United States, Virginia, or Loudoun County, those parts that are not held invalid shall continue in full force and effect.

    I hereby grant my permission to my dependent to participate in the above-referenced activity or event, subject to all of the above terms and conditions and information provided.

    I hereby agree to waive any and all claims that I may have, either directly or indirectly, against Little Hands Speech Therapy, its employees, and contractors as result of any and all injuries to my dependent or damage to property of my dependent in relation to his or her participation in the activity or event sponsored by Little Hands Speech Therapy, including any claims that occur during, resulting from, or related any travel to or from the event or any travel arrangements and further agree to indemnify, reimburse, and forever hold harmless Little Hands Speech Therapy, it’s employees, and contractors from any and all injuries, costs, damages, causes of action, claims and any consequential and incidental damages arising out of or resulting from any injury, death, or damage to property which my dependent may sustain as a result of his or her participation in this activity or event sponsored by Little Hands Speech Therapy, including any such injuries, costs, damages, causes of action, claims and any consequential and incidental damages occurring during, resulting from, or related to any travel to or from the activity or event or any travel arrangements or transportation provided as a part of this activity or event.

     

    Participant’s Name:

    Parent or Legal Guardian Signature:


     
    Yes! I would like to receive the quarterly email newsletter.No, I would prefer not to be added to the email list at this time.