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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 confidentsolutions7@gmail.com . I am signing up for:

April 23rd-May 28st : ________Social Learning through self-awareness/self-monitoring $225.00 3:00-4:00

April 23rd-May 28st : _________Theory of Mind/Zones of Regulation $225.00 4:00-5:00

April 23rd-May 28st: __________ Practicing Social Learning $225.00 5:00-6:00

*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.