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Social Learning Groups Registration Form

School Session 2009

Student Name Age:
Parent A Parent B
Daytime phone: Alternate phone:
Address
City
State Zip
E-mail

A deposit of $140.00 for groups (3 or more students) or $160.00 for dyad (2 students) equaling the cost of the first two sessions is required for us to either hold a space or to try to develop a group for your child. The deposit goes toward the fee for the first month of therapy. The remaining balance ($70.00 per group session for a group of 3+ students or $80.00 per dyad for a group of 2 students) is due at the end of the month. Subsequent payments will be expected at the end of each month.

The School Session groups will be running continuously throughout the school year and we require a one month notice if you decide to have your child withdraw from their group placement. Over the school year, you will have 2 excused absences for any reason, however beyond that; missed sessions will be billed as a regular session. This is because group work is dependent upon all group members attending as much as possible. We will observe all major school holidays and will take a 2 week winter break (please see the calendar on our web site).

Please initial and sign below to indicate your agreement with the following statements.

I understand and agree that the Communication Works therapists will determine if my child is appropriate for group therapy and will arrange groups according to age, diagnosis, and abilities. My child will then be placed in the most appropriate group as determined by these therapists. If there are no openings in that group, I will have two options: Place my child on a waiting list, holding a place in the group with my deposit, or receive a refund of my deposit, and re-enroll at some unspecified time, holding no place for my child.

Students will be videotaped or photographed for clinical and therapeutic purposes unless otherwise specified.

Initials Date
Printed Name Date
Signature

 


Please make checks payable and send registration forms to:

Communication Works
4400 Keller Avenue, Suite 200
Oakland, CA 94605


Communication Works
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