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CONTACT US:

757-422-6342

info@socialbutterfliesclub.com

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FIND US:

600 Independence Blvd

Virginia Beach, VA 23456

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Schedule Information

Please select a day and time you prefer. We will contact you with an appointment.
The best day for me/my child is*
The best time is*
I am interested in*
- an in person screening (all ages)
- a virtual screening (ages 6 and older)
Client Information- Pediatric ONLY (ages 2 1/2-17) *ADULT Clients, Please scroll to the form below for the Adult Intake Form
Child Information
My Child's Name*
First Last
My Child's Date of Birth*
MM slash DD slash YYYY
Child's current grade level*
Child's current school
My child's main communication method is*
- Verbal
- Sign Language
- Communication Device
- Picture Communication
- Non-Verbal
Does your child have difficulty asking and/or answering questions? (with peers or adults)*
- Yes
- No
Does your child have difficulty taking turns with others? (During an activity and/or verbally)*
- Yes
- No
Does your child have difficulty making friends because he/she prefers to play alone or does not like to share?*
- Yes
- No
Does your child walk around the perimeter of the playground or prefer to play in the sand box?*
- Yes
- No
Does your child “get stuck” on one topic or type of toy?*
- Yes
- No
Does your child have a speech-language delay or a fine/gross motor delay?*
- Yes
- No
Does your child have difficulty in the classroom setting and following the rules of the class? (Sitting for circle time or structured tasks,standing in line, following directions, etc.)*
- Yes
- No
Does your child CURRENTLY have behaviors that are NOT typical of peers that interfere with their daily activities (playing with peers, transitioning to tasks)? PLEASE NOTE that we are NOT able to accommodate the following behaviors if they are not being addressed by a behavioral professional: elopement, hitting, kicking, biting, spitting, destruction of property, or harmful behaviors to self or others.*
ALL INFORMATION WILL REMAIN CONFIDENTIAL AND IS FOR ASSESSMENT PURPOSES ONLY
- Yes
- No
Has your child received any intervention for these behaviors?*
ALL INFORMATION WILL REMAIN CONFIDENTIAL AND IS FOR ASSESSMENT PURPOSES ONLY
- Occupational Therapy- Self Regulation/Sensory Integration
- ABA (Applied Behavior Analysis)
- PCIT (Parent Child Interactive Therapy)
- Behavior Therapy/Play Therapy with Psychotherapist
- 1:1 Psychotherapy with therapist or counselor
- OTHER- Please explain in comments below
Please give us details on the types of behaviors your child exhibits. Please note any elopement, hitting, kicking, biting, non-compliance, etc. and the possible causes for these behaviors. PLEASE NOTE that we are NOT able to accommodate any of the above noted behaviors if they are not being addressed by a behavioral professional. We are happy to refer to a local behavioral specialist if the behaviors are not being currently addressed.*
ALL INFORMATION WILL REMAIN CONFIDENTIAL AND IS FOR ASSESSMENT PURPOSES ONLY
Tell us about your concerns (optional)
Parent Information
Parent Name*
First Last
Email Address*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone number*
Number where you can be reached to schedule an appointment
Referred by (please check one)*
- Doctor
- Family
- Friend
- Close to Home/Work
- Website
- School
- Other
If "Doctor", enter the doctor's name
If "Other", enter more information
GROUP Preference*
- Town Center Area: 600 Independence Blvd. Virginia Beach, VA 23462
- VIRTUAL Social Group via secure Teletherapy Platform
* Please note that group days and times vary from semester to semester. We will do our best to accommodate your preference but it is not guaranteed.
I understand that there is a placement screening fee of $85.00 that is due at the time of service*

* Enter your initials
I would like to pay my $85 placement screening fee now using my credit card*
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- Yes
Placement Fee
Price:
Total
$0.00
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Supported Credit Cards: American Express, Discover, MasterCard, Visa
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ADDRESS

600 Independence Blvd
Virginia Beach, Virginia 23456

**We are located BEHIND SonRise Church

PHONE & EMAIL

(757) 422-6342
info@socialbutterfliesclub.com

About Us

The Social Butterflies Club was founded in 2004 by Rhonda Osisek M.S., CCC-SLP. Rhonda created this program for a few of her clients that were having trouble interacting appropriately at school.