Confident Solutions, LLC
Mindful Thinking for Social Expectations
I am signing up for:
Feb.26th-April 2nd : _________Theory of Mind and Executive
Functioning $225.00 3:00-4:00
Feb. 26th-April 2nd : _________Learning how to change a behavior
through self-awareness $225.00
K-2 meets 4:00-5:00 and 3rd-5th meets 5:00-6:00
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.
