Name*

First NameLast Name

Preferred Name

Date of Birth*

Date

Age*

Preferred Pronouns

Name*

First NameLast Name

Email*

example@example.com

Yes PleaseNot at This Time

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact (Name + Phone)*

Please list name, phone number, and relation to child.

December 3 Week Mini Session

4 Week Session (Starting February 2026) (Ages 0-3)

4 Week Session (Starting January 2026) (Ages 4-8)

4 Week Session (Starting February 2026) (Ages 4-8)

Please confirm the time slot you selected*

Are there any allergies or medical concerns we should be aware of?*

Please list for each child being registered

Sensory Preferences

Noise, lights, textures, etc. Please list for each child being registered

How does your child typically interact with peers in group play?

Please list for each child being registered

YesNo

If yes, please explain.

Please name which child or list explanations for each child being registered

Are there any safety concerns we should be aware of?*

Elopement, aggression, etc. Please name which child or list explanations for each child being registered

Contract For Social Skills Enrichment Groups

Program Description

These Social Skills Enrichment Groups are non-clinical, play-based groups designed to support peer interaction, communication, emotional development, cooperative play, and confidence building. While these groups are not ABA therapy, your child benefits from activities thoughtfully designed by a masters level clincian Board Certified Behavior Analyst (BCBA), using evidence informed strategies to maximize social engagement and learning opportunities in a fun, peer focused environment.

These groups are not ABA therapy, do not include treatment plans, and are not a replacement for clinical services.

Sessions include:

BCBA led, play based social activities
Small peer groups
Turn taking, communication, and cooperative games
Sensory friendly structure

Sessions do not include:

Individualized ABA programming
FBAs or assessments
Treatment planning or data collection
Insurance billing

Program Scheduling & Enrollment Policy

We reserve the right to cancel, reschedule, combine, or modify group sessions due to low enrollment, staffing availability, facility constraints, weather, safety concerns, or other unforeseen circumstances.

In the event a group session or series is canceled by Behavioral Horizons ABA LLC, families will be notified as soon as reasonably possible. Any prepaid fees for canceled sessions will be credited toward future groups or refunded at the discretion of Behavioral Horizons ABA LLC.

Attendance & Makeup Policy

Cancellations made by Behavioral Horizons ABA LLC due to other events occuring at the building, weather, or if staff becomes unavailable, the class will be credited towards the next monthly session or a makeup class may be offered. If the family has chosen to cancel their registation for the following month, they may recieve a refund for the class that was cancelled by Behavioral Horizons ABA LLC. We will notify families if group will be cancelled as soon as possible.

If your child misses a session, a makeup class may be scheduled. The family is responsible for initiating the makeup by emailing kpaquette@behavioralhorizonsaba.com within one week of the missed session. After one week, the makeup opportunity expires.

Behavioral Horizons ABA LLC will provide one makeup class option. If your family is unable to attend that option, Behavioral Horizons ABA LLC is not required to offer additional alternatives. Confirmation of the makeup class must be received and approved by Behavioral Horizons ABA LLC prior to attending.

Please note: There are no refunds for missed classes.

Children may not attend if they have:

Fever within the past 24 hours
Vomiting or diarrhea
Contagious illness
Any undiagnosed rash

Please notify us as soon as possible if you know your child will not be attending group.

Note: Consistent attendence is important for group cohesion. If there are two or more unexcused absences during a 4 week session, you may be put back on a waitlist for upcoming sessions at the discretion of Behavioral Horizons ABA LLC.

Fees & Payment

The standard program rate is $140 per child (and $119 for a sibling in the same family) for a 4 week session. Sessions occur once per week at your scheduled time and are 1 hour long. Payment is due at the time of registration. Your child's spot is not reserved until payment has been recieved in full. All registration fees are nonrefundable.

A card must be kept on file. Families will be automatically charged for each child enrolled on the 15th of the month to secure their child's spot in the next 4 week session. Behavioral Horizons ABA LLC will contact you after initial payment/registration has been recieved to manually add a card to your file. If you do not wish to enroll in the upcoming session, you must notify Behavioral Horizons ABA LLC by emailing kpaquette@behavioralhorizonsaba.com on or before the 14th of the month to avoid being charged. Notification of cancellation on the 15th of the month or later does not qualify for a refund. These charges are nonrefundable.

Facility Agreement

Behavioral Horizons ABA LLC partners with Cafe Neelu/Fuel America for use of their facility.

Parents agree to:

Follow all building rules
Supervise siblings not enrolled in the group
Respect shared spaces

Cafe Neelu/Fuel America is not responsible for supervision or management of the group.

.......................................................................................................................

Parents are required to stay for the duration of group for children ages 0-8 years old.

I consent to my child being photographed/recorded.I consent only to non-identifying photos (face covered, turned away, hands/activities only).I do not consent at this time.

Liability Waiver: By agreeing below, I understand that social skills enrichment groups involve play-based activities that may include physical movement, interactions with peers, and use of equipment within Cafe Neelu/Fuel America. I acknowledge that Behavioral Horizons ABA LLC & Cafe Neelu/Fuel America take reasonable steps to provide a safe environment. I understand that participation involves inherent risks including but not limited to minor injuries (such as bumps, falls, or scrapes). I agree that I assume full responsibility for my child's participation. I hereby release, waive, and hold harmless Behavioral Horizons ABA LLC, its owners, staff, contractors, and affiliates, as well as Cafe Neelu/Fuel America and its owners and staff, from any and all liability, claims, or demands for personal injury, property damage, or other loss that may arise from my child’s participation, except in cases of gross negligence or intentional misconduct. I understand that I may withdraw my child from participation at any time.*

I agree and accept the Liability WaiverI do NOT agree (I understand this means my child cannot participate)

Social Skills Enrichment Groups offered by Behavioral Horizons ABA LLC are designed to support social skill development, communication, and peer interaction in a fun, play-based setting. These groups are not ABA therapy and are not a substitute for medical, psychiatric, psychological, or other healthcare services. Participation does not diagnose or treat medical or mental health conditions. If you have concerns about your child’s medical, behavioral, or mental health needs, you are encouraged to consult a qualified healthcare professional, such as your primary care physician or a licensed specialist.*

I Understand

Parent/Guardian Name*

First NameLast Name

Signature*

Date*

Date

Please select the number of children you are registering*

4 Week Session

1 hour per class

$140.00 Quantity

4 Week Session (Sibling)

1 hour per class (must have another child in the same family registered)

$119.00 Quantity

Enter coupon

Total

$0.00

Payment Methods

Credit Card

ACH Bank Transfer

Social Skills Enrichment Group Sign Up

Child Information

Parent/Guardian Information

Session Selection and Child Support Needs

Contract For Social Skills Enrichment Groups

Agreement & Payment Acknowledgement

Payment

Payment Methods