Confident Solutions, LLC

Mindful Thinking for Social Expectations

I am signing up for:

Aug. 20th-Oct. 1st; Session 1 Grades K-2nd : _________ 2:00-3:00, $225.00

Aug. 20th-Oct. 1st; Session 2 Grades 3rd-5th : _________3:00-4:00 $225.00

Aug. 20th-Oct. 1st; Session 3 Practicing of Skills:_______4:00-5:00 $225.00

Reminder: There will be no classes on Sunday, September 3rd*

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. The registration fee covers your and your child’s spot for the six-week session. No refunds are issued for any missed classes during this time.