Social Skills Group Intake Form

I have reviewed the information on the Social Skills Group page:*

Client Name*

First Last

Age*

Please enter a value between 0 and 100.

Client Gender*

Name of School or Occupation

Parent or Other Contact Name (If Applicable)

First Last

Relation to Client (If Applicable)

Phone #*

Email - we are having trouble receiving forms that use a yahoo.com address please use an alternate email address*

Referral Source*

Which group(s) are you most interested in joining?

Previous Diagnosis (If Applicable)

Is interest in our services in relation to any court-related issues?*

If parents are separating or divorced, are both parents in agreement to access our services?*

Additional Comments

Out-of-Network*

By checking this box, I understand that Spectra Therapies is out-of-network and does not accept any insurance. More information on how to find out about your insurance out-of-network benefits is provided under About Us - Insurance Guide.