Growth Opportunity Center Social Skills Groups

Please complete this form to begin the process of enrolling your child in Social Skills groups at the Growth Opportunity Center. You will receive a phone call or email notifying you that we have received your request. If you have any difficulty with the form, please leave a message for Dr. Mary Coakley at 215-947-8654, extension 248.

* Required

Name of Child *

Gender *

Male
Female

Child's Date of Birth *

Name of parent requesting information *

Mailing Address *

Best Phone number *

Parent's email address

Child's School and District

Child's Grade

Your child's most recent diagnosis (if applicable)

(If your child was given a diagnosis from the school, from a psychologist, psychiatrist, or developmental pediatrician)

Does your child take any medication for psychological/behavioral problems?

If so, please list

This is a required question

How did you hear of our groups?

The Growth Opportunity Center may be able to use your insurance to pay for the group. This will be discussed with you. What type of medical insurance do you have?

GOC does not accept Medical Assistance (MA).

Other pertinent information