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Speech Therapy
Social Skills Program
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Please Confirm Attendnece
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Indicates required field
Will your child be attending the Social Skills Group beginning July 15, 2015
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Yes
No
Child's Name
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First
Last
Likes and Interests
Please check any of the items that may be of interest:
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Movies
Puzzles
Internet
Cooking
Machines
Sports
Television
Going to Theatre
Space/Planets
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Books
Action Figures
Legos
Dancing
Pirates
Animals
Board Games
Wii / Playstation
Cars/Trains/Trucks
Magic
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Arts & Crafts
Dolls
Computer Games
Music
Science
Resturants
Comics
Card Games
iPad
Favorite Movies
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Favorite Toys
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Favorite TV Shows
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Favorite Foods
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Favorite Characters
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Favorite Color
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Favorite Video Games
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Favorite Books/Comics
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Other Special Interests
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Dislikes and Aversions
Please check any of the items that may be aversions:
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Movies
Dancing
Clocks Ticking
Slimy textures
Fluorescent Light
Animals
Low Pitch Sounds
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Thunder
Television
Music
Crying of others
Cold Temperatures
Hot Temperatures
High Pitch Sounds
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Waiting
Traveling
Books
Machines
Dogs Barking
Please list any other specific dislikes:
Loud Noises
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Tactile Textures
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Clothing
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Foods
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Smells
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Specific Aversions
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Other Information
Does your child have pets? Please specify type and names.
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Does your child have siblings? Please specify ages.
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Please Specify any Food Allergies or Aversions
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Other Important Information
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