New Client Likes Dislikes

Please Confirm Attendnece

Will your child be attending the Social Skills Group beginning July 15, 2015 *

Yes No

Child's Name *

First

Last

Please check any of the items that may be of interest: *

Movies Puzzles Internet Cooking Machines Sports Television Going to Theatre Space/Planets

. *

Books Action Figures Legos Dancing Pirates Animals Board Games Wii / Playstation Cars/Trains/Trucks Magic

. *

Arts & Crafts Dolls Computer Games Music Science Resturants Comics Card Games iPad

Favorite Movies *

Favorite Toys *

Favorite TV Shows *

Favorite Foods *

Favorite Characters *

Favorite Color *

Favorite Video Games *

Favorite Books/Comics *

Other Special Interests *

Please check any of the items that may be aversions: *

Movies Dancing Clocks Ticking Slimy textures Fluorescent Light Animals Low Pitch Sounds

. *

Thunder Television Music Crying of others Cold Temperatures Hot Temperatures High Pitch Sounds

. *

Waiting Traveling Books Machines Dogs Barking

Please list any other specific dislikes:

Loud Noises *

Tactile Textures *

Clothing *

Foods *

Smells *

Specific Aversions *

Does your child have pets? Please specify type and names. *

Does your child have siblings? Please specify ages. *

Please Specify any Food Allergies or Aversions *

Other Important Information *

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