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Blue Cross/Blue Shield PPO Members ---

We can direct bill for you. Please provide required information below:

For all other insurance carriers or if not submitting an insurance claim,
please submit only the information above and we will contact you.

Social Skills groups are a good opportunity for children to learn needed skills within
a group of their peers. Our 6-week class
is designed to lead to better interpersonal skills, increased emotional regulation, conflict resolution, problem-solving
and coping.

Building Social Skills

Feel Free To Call Us at 630.759.4000

If You Have Any Questions or Need Additional Information.

Other key areas

addressed in the
Social Skills groups are:

6-week groups to meet
on the following dates:

1/20, 1/27, 2/10, 2/24,

3/10, 3/17/2017

P Self-Esteem P Patience P Friendship Skills P Anger Management P Confidence P Decision Making

5-8 YEAR OLDS meet from 8-9am

9-12 YEAR OLDS meet from 9-10am

13-16 YEAR OLDS meet from 10-11am

Child’s Name: Enter Name

Parent/Guardian’s Email Address: Enter Parent/Guardian’s Email Address

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Briefly Tell Us Why You are Registering Your Child: Enter Briefly Tell Us Why You Are Registering Your Child

Parent/Guardian’s Phone Number: Enter Parent/Guardian’s Phone Number

Home Address: Enter Address

Child’s Birthdate: Enter Child’s Birthdate

Parent/Guardian’s Name: Enter Parent/Guardian’s Name

Policy Holder’s Name: Enter Policy Holder’s Name (optional)

Policy Holder’s Birthdate: Enter Policy Holder’s Birthdate (optional)

BC/BS Member ID #: Enter BC/BS Member ID # (optional)

BC/BS Group #: Enter BC/BS Group # (optional)

404 West Boughton Road, Suite A, Bolingbrook, Illinois 60440 • Office: 630-759-4000 • mgibson@drmsgibson.com