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Peer & Sibling Relationship Skills Boot Camp Registration/ Interest Form

A 4-week summer small-group program to help children build communication, emotional regulation, flexibility, conflict-resolution, and peer/sibling relationship skills.

The program includes 6 child group sessions and 2 parent guidance sessions. Completion of this form does not guarantee enrollment. Children will be thoughtfully matched based on age, developmental level, goals, and group fit.

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Parent/Guardian Info ^*

First Name ^*

Last Name ^*

Email ^*

Phone Number ^*

Relationship to Child ^*

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Second parent/guardian Info

Optional

First Name

Last Name

Phone Number

Relationship to Child

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Child’s Info ^*

First Name ^*

Last Name ^*

Age, Grade Level (Upcoming School Year) ^*

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If a sibling is also interested in joining, please provide the sibling’s info.

First Name

Last Name

Age, Grade Level (Upcoming School Year)

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Which cohort may work for your family? ^*

Mid-June to Mid-July

Mid-July to Mid-August

Either may work

Need more schedule details first

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Are there days/times that do NOT work for your family?

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What areas would you like your child to strengthen?

Communication

Emotional regulation

Flexibility

Conflict resolution

Peer relationship skills

Sibling relationship skills

Other

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How does your child usually do in small-group settings? ^*

Usually does well

Does well with some adult support

Needs frequent adult support

Can become overwhelmed or dysregulated

Not sure

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What topic(s) would you like support with during the parent guidance sessions? ^*

Managing sibling or peer conflict

Supporting emotional regulation

Improving communication at home

Reducing escalation

Building flexibility and compromise

Helping skills carry over at home

Other

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Please review the following statements: ^*

This form is for program interest and does not guarantee enrollment. Children will be thoughtfully matched based on age, developmental level, goals, and group fit.

This program is separate from regular individual therapy and focuses on educationally related social-emotional and relationship skills. It is not a substitute for individual therapy, family therapy, crisis support, or emergency services.

The program fee is $1,200 per child for the full 4-week program.

Dr. Yam may contact you to discuss whether the group is an appropriate fit for your child.

I have reviewed and acknowledge the information above

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Thank you!

Dr. Yam will follow up with you

regarding next steps for registration and enrollment.

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