Thank you for your interest in the Social Navigations Group- An Autplay Based Play Group at Bloom Child Therapists!

This form is intended to help the group leaders curate a positive and inclusive group environment for all participants.

Group is limited to 6 participants.

Dates: October 25-December 14 (8 sessions total)

Time: Saturdays 10:15-11:30 AM

Location: Bloom Child Therapists Office, Suite 200

Who should attend: Individuals ages 9-11 who are neurodivergent (autistic children, those with ADHD, social anxiety, sensory differences, learning differences, and developmental and physical disabilities) and express a difficulty and a desire to have support with social navigation; specifically engagement, teamwork, advocating, connecting, sharing with others, perspective-taking, executive functioning, and including others.

Cost: $400 for 8 sessions (no discounted rate for missing sessions)

Upon submission of this form, you will be contacted by the group leader, Keri Sawyer, LPC, RPT-S to discuss next steps.

Child’s Name *

Child's Age *

Caregiver's Name *

Caregiver's Phone *

Caregiver's Email *

I Consent to Receive Email & SMS Notifications from Bloom Child Therapists. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

What diagnosis (if any) does your child have?

Describe your child’s social interaction and play preferences.

Describe your child’s communication style and preferences.

Has your child ever participated in a therapy or play group before? If so, what was the experience like for your child?

What does your child like to do for fun?

What are some of your child’s interests?

What community/public activities has your child participated in that they seemed to enjoy?

What community/public activities has your child participated in that they seemed to NOT enjoy?

What seems to help your child regulate, calm, or relax?

What sensory differences (if any) does your child seem to respond negatively to (large crowds, noise, etc.)?

What would you like to see improve for your child by participating in this group?

What do you feel would be your child’s biggest challenge with participating in this group?

Would your child do well with older children, younger children, children of the opposite gender?

How would you like this group to assist you as a caregiver?

Are you willing to participate in the group experience with your child?

Any additional information you would like to share with us about your child?