Individual & Group Counseling Application | Social Buds of Connecticut, LLC

Counseling Registration

Choose the counseling service(s) you are registering your child for:

Individual Counseling

Social Buds Workshops

First Name

Last Name

Phone

Relationship to Child

Child's Full Name

Child's Age

Child's Grade

Child's School

Emergency Contact 1 Name

Relationship to Child

Emergency Phone 1

Emergency Contact 2 Name

Relationship to Child

Emergency Phone 2

Authorized Pickup Person 1

Relationship to Child

Auth. Person 1 Phone

Authorized Pickup Person 2

Relationship to Child

Auth. Person 2 Phone

Authorized Pickup Person 3

Relationship to Child

Auth. Person 3 Phone

Does your child have allergies? If so, please list them:

Does your child have an active IEP or 504 Plan? If so, what is the disability?

Please list your child's strengths:

Please describe the areas you would like us to work with your child:

What is your child's favorite color?

Your child's favorite interest / hobby:

Policy Statements:

No-Shows: Only individual counseling sessions may be rescheduled if cancelled within 24 hours. If your child misses a group counseling session, refunds and make-ups are not allowed.
Early Arrivals: Please do not drop off your child prior to their scheduled time. The time of opening and closing may vary depending upon situations beyond our control, such as snow.
Check-in / Checkout: For safety and security reasons, all children are required to check in / checkout with their parents/guardians face to face with a staff member. At any time during check-in / check-out, we reserve the right to require to see a valid photo identification. In the event another person is picking up your child, they must be on the authorize pickup list.
Food & Drink: Due to other children's allergies, food and drink are not permitted during services. Water is allowed.
Late Pickup: Your child must be picked up on time. In the event that you are unable to pick up your child, you must make alternate arrangements. Should you fail to pick your child up by his or her scheduled time a penalty will be applied. A late pick-up penalty of $20 for every fifteen minutes or part thereof will be assessed. If late pickup occurs more than 2 times in one month, we reserve the right to remove your child from the program without refund.
Left Child: In the event that a child has not been picked up by the end of the scheduled service/session, every attempt will be made to contact the parent(s) of the child after 15 minutes of closing time. The staff will contact all parental phone numbers including cell phone, work phone, and home phone. If neither parent nor emergency contact person can be reached within a half-hour period after closing, it is the responsibility of Social Buds to contact the police who will be called to the service/session location to assume supervision of the child. The Trumbull Police non-emergency line is (203) 261-3665.
Medical Coverage Required: You must provide proof of medical coverage for your child. We do not allow children to be enrolled without family Health Insurance coverage. You agree to not hold Social Buds of Connecticut, LLC financially liable should your child/children get injured while under the care of Social Buds of Connecticut, LLC.

I have read, understand, and agree to the policies statement above.

Your Signature