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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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Please provide the primary parent/guardian’s information. You’ll have the option to add a second caregiver below.

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Primary parent/guardian full name ^*

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Primary email address ^*

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Primary phone number ^*

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Relationship to child (e.g., mother, father, guardian) ^*

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Preferred contact method(s) ^*

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Would you like to add a second parent/guardian contact? ^*

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Second parent/guardian full name

If applicable

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Second parent/guardian email address

If applicable

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Second parent/guardian phone number

If applicable

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Second parent/guardian relationship to child

If applicable

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We’ll use this information to help determine age/developmental fit and group matching.

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Child’s full name ^*

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Child’s age

Optional (we can calculate from date of birth)

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Is a sibling also interested in joining? ^*

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If yes or maybe, please list sibling’s name, age, and grade.

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Examples: frequent sibling conflict, peer challenges, big reactions, difficulty compromising, trouble repairing after disagreements.

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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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Any summer camps, sports, travel, or scheduling conflicts I should know about?

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Include any relevant supports, accommodations, or strategies that work well.

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What would you hope your child gains from this program?

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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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Registration helps us evaluate fit and plan cohorts. Dr. Yam will follow up with the next steps (e.g., brief intake call, scheduling, and enrollment details).

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Please review the following statements: ^*

This is an interest form 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.

This program focuses on educationally related social-emotional and relational skills.

This program 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 me to discuss whether this group is an appropriate fit.

I have reviewed and acknowledge the information above

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Is there anything else you would like Dr. Yam to know?

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Parent/guardian signature ^*

Type your full name to sign.

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Signature date ^*

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