Social Boundaries Application Form

Please fill out and submit your information

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* 1. Name

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* 2. Email address

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* 3. Your daytime phone number

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* 4. Select Session

Add me to the waitlist for children (8-13 years old) with high functioning autism

Add me to the waitlist for youth and young adults (ages 14+)

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* 5. Child's Name

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* 6. Child's Age

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* 7. What is your child's primary and other special needs?

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* 8. Share with us your child's approximate level of social functioning

Pre-K

Early Elementary

Late elementary

Adolescence

Young Adult

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* 9. Tell us about your child's experiences with group activities

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* 10. List behavioral concerns that need to be considered to ensure your child's safety

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* 11. How can PHP provide your child the most positive learning experience?

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* 12. List any aversions your child might have

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* 13. What motivates your child?

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* 14. Share any information that will assist us in better reaching your child

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* 15. Please advise us of any health issues, food allergies, etc.

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* 16. Are there any family circumstances of which we should be aware?