Enroll in our Social Skills Program

Step 1 of 6

Social Skills Camp Registration Form

Child's Information:

Thank you for completing the intake form. We appreciate your attention to detail and look forward to providing your child with support and guidance in developing their social skills.

Child's Name(Required)

First Last

Preferred Name (if different):

Age

Date of Birth

Grade (if applicable)

Gender:

School Attending (if applicable):

Are you a current STP patient?

Yes

How did you hear about us

Parent/Guardian Information:

Name

First Last

Relationship to Child:

Contact Number (Primary):

Contact Number (Secondary):

Email Address:(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Enroll in our Social Skills Program

Social Skills Camp Intake Form:

Social Skills Camp Registration Form

Child's Information:

Parent/Guardian Information:

Emergency Contact Information:

Health Information:

Social Skills History:

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