Intake Form-Social Skills Groups

Arranging social skills groups requires a great deal of consideration. We try our best to meet everyone's needs. In order for this to be as successful as possible, please answer the questions below to the best of your ability.

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Parent/Contact *

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Last

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Child Name *

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Last

Email *

Phone Number *

Age & Date of Birth (month and year only) *

Where is your child currently attending school *

Is your child verbal? *

Is your child able to express their wants, needs and preferences? *

Is your child able to identify the emotions that they are feeling? *

Does your child identify emotions in others? *

Does your child follow multi-step directions? *

Is your child agressive towards peers? *

Is your child agressive towards self? *

Does your child prefer to play by himself/herself or join in activities with others? *

Does your child understand humor? *

Does your child follow rules during games? *

Is your child accepting of comfort from others when upset? *

Is your child able to calm himself/herself down when upset? *

Does your child accept losing a game without becoming overly upset? *

Does your child understand that his/her behavior impacts peers? *

Does your child accept making mistakes without becoming overly upset or angry? *

Does your child have a sense of pride in his/her achievements? *

What are some typical activities that your child engages in? (iPad games, playing with blocks, listening to music, etc.) *

Health Insurance Plan *

Please choose the best day for your child to attend. *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please choose the time block that best fits your needs to attend group. *

4:00 pm - 5:00 pm (M-F) 5:00 pm - 6:00 pm (M-F) 6:00 pm - 7:00 pm (M-F) Saturday afternoon

Use this space as needed to describe any additional information regarding the best days and times to attend. *

How did you hear about our program? *

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