The Squared Circle
Please fill out the form below to sign up for Creative Approach Development Center's new social group for Professional Wrestling fans, The Squared Circle. Please keep in mind that submission of this form does not verify enrollment in the club and that an intake meeting will be conducted (either in person, virtually, or by phone) to make sure the club is the right fit for your student. If you have any questions, please email info@CreativeApproachOnline.com or call 804-876-2115. Also, be sure to follow The Squared Circle on Facebook and Instagram to get the latest updates and info about club happenings and events.
Participant's Name
First Name
Last Name
Caregiver/Provider Name
First Name
Last Name
Caregiver/Provider Email
example@example.com
Caregiver/Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver/Provider Phone Number
Please enter a valid phone number.
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Participant's Birthday
-
Month
-
Day
Year
Date
During our meetings, participants will have the opportunity to play games, participate in discussions, complete arts and crafts projects, and watch wrestling. Will your participant require any accommodations or resources to participate in the club and complete the activities?
Yes
No
I am not sure
If yes, please describe
What do you and your participant hope to gain by participating in The Squared Circle?
Who are some of the participant's favorite wrestlers?
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Participant medical and/or mental health diagnoses
Light snacks will be provided during the meeting. Please list your participant's allergies or dietary conditions
While this is a group that includes lessons and supports to help with social skill development, it may not be appropriate for those who engage in high levels of challenging behaviors. Does your participant engage in any of the following behaviors? (**Check all that apply. Answering yes does not guarantee participant will not be able to participate)
Emotional outbursts (crying, screaming, yelling, refusing to participate, disruption of activities, etc.)
Verbal aggression (name calling, making threats, using profanity, etc.)
Physical aggression (hitting, kicking, pinching, biting, throwing objects at others, etc.)
Property destruction (throwing things, knocking things over, punching things, tearing up others items, etc.)
Walking off/Eloping (leaving the room without permission, not returning when called back)
Interrupting others (talking when others are talking, making rude comments when someone says something they do not understand or disagree with)
Refusal to participate (does not participate in group activities and rushes others who do)
By entering my name below, I agree that I have been notified that there is a $10 fee to attend each session of The Squared Circle that will be required before the meeting starts to help cover the cost of snacks, materials, and prizes.
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Intake Interviews are meetings conducted by Dr. Levi-Shackleford on Mondays and Thursdays between 3:00 pm and 5:30 pm. They typically last about 20-30 minutes and are currently being conducted virtually or by phone. They provide you with the opportunity to learn more about The Squared Circle and share your participant's interests and support needs. Please select a day and time for your intake interview.
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