Preliminary L.O.T.U.S. CLUB Intake

Preliminary L.O.T.U.S. CLUB Intake

We’re excited that you have an extraordinary kid who is ready for a lot of social fun!
The L.O.T.U.S.Clubs @ AHA! are all social practice clubs and are perfect for kids who have been working at developing social skills and need a supportive environment to continue to practice what they have learned. To help us get to know your child, please take a few minutes to complete this initial information survey.

Once we receive it, we will contact you by email to set up a complimentary phone consultation with you.

Warmly, Karen
Founder and Director of the L.O.T.U.S. Clubs @ AHA!
What club are you interested in enrolling your child?
Parent Name:

First NameLast Name
Email
example@example.com
Child's name:

First NameLast Name
DOB/Age
FM
School/Grade
Please share your child’s strengths and interests:
Please share your child’s social challenges and growing edge:

Does your child...

	Dependent on adult prompt and support	Independent skill at home and school, practicing phase	Mastered skill and sets strong example for peers
Participate in groups independently?
Enjoy small group activities?
Follow directions first time asked?
Communicate with others easily?
Share play items and talk space with peers?
Take turns with peers?
Use good communication skills to solve problems?
Enjoy outdoor activities?
Enjoy collaborative projects with peers at school or home?
Wants to take the lead in group activities?

What 2-3 social goals are your child working on at this time?
Goal 1
Goal 2
Goal 3
Please share any additional information that would help us get to know your child’s needs better
Once you click the Submit button below, you will be redirected to a page to schedule a complimentary call with our director to finalize the sign up process.

Hit SUBMIT and the journey begins!
Should be Empty: