Fall 2023 Social Group Interest Form

We are excited to be collaborating with the ESU Speech Clinic to offer social groups for individuals with ASD. Clients will be paired with an ESU Student who is currently matriculated in the Speech Language program preparing for a career working with those with special needs.

The groups will be offered on Wednesdays from 5p-6p on the ESU Campus in Monroe Hall. Participants will be grouped by age, which is dependent on the number of participants. The first session will be an evaluation session to determine if we are able to accommodate your child for the semester. If, after the 1st session we determine our social group format is a good match for your child, there will be a $200 registration fee for the subsequent 8 weekly 1 hour sessions.

We look forward to working with you and your child! Please feel free to contact Dr. Rachel Chapman with any questions or concerns at rchapman@esu.edu.

Participant Name Participant Name * First Last
Parent/Caregiver Name Parent/Caregiver Name * First Last
Age of Participant *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address *
Please describe the social skill deficits which your child currently demonstrates (description, frequency, duration, setting). *
Legality and Waivers
Services offered through the ESU Autism Education Center will be clearly separate from any school based programming and focused solely on knowledge gaps which impeded individuals rate of success socially and in daily living within the home and community settings. Families will be required to acknowledge, release, and waive all liability of ESU and its staff and students in regards to rate of progress made during the skills building process and acknowledge that service providers are providing services as part of their educational requirements. Families will further be required to acknowledge that all services and skills instruction provided by the Center are supplemental and stand alone to any educational or agency based therapies they currently receive, and therefore, not subject to due process. Center staff will implement non-restrictive positive behavioral support and de-escalation techniques and will not provide any physical support to clients. Parents must stay at clinic and immediately respond if behaviors cannot be de-escalated through verbal prompts, etc. Parents or caregiver is required to be in attendance during the weekly sessions. Additionally, parents acknowledge any data collected during this program can be used for research and publication, with any personal information being e-identified. Social groups will be planned and implemented by ESU students, and monitored by a licensed professional in the field/ ESU faculty member. We reserve the right to determine if our group is appropriate for your Childs needs, and the reserve the right to deny attendance if aggressive or disruptive behaviors are exhibited. By checking the below box, I agree to all of the above. *