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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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Email
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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*
Date Format: 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
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 Location Preference*
- Town Center Area: 600 Independence Blvd. Virginia Beach, VA 23462
- Great Neck Area: 1157 First Colonial Road Suite 301 Virginia Beach, VA 23454
- General Booth Area: 2117 McComas Way Suite 105, Virginia Beach, VA 23456
- Kempsville/Chesapeake Area: 5301 Providence Road Suite 90 Virginia Beach VA 23456
- 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*
- No
- Yes
Placement Fee
Price: $85.00
Total
$0.00
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ADDRESS

600 Independence Blvd
Virginia Beach, Virginia 23456

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.