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Search for:
About
Services
Clinic
Teletherapy
Summer Programs
Blog
Resources
Contact
What We Treat
Employment/Volunteering
Referral Form
About
Services
Clinic
Teletherapy
Summer Programs
Blog
Resources
Contact
What We Treat
Employment/Volunteering
Referral Form
06-Summer Programs- Foundational Social Skills Group Intake Form (Ages 5–7)
Narissa
2025-03-31T19:37:27-07:00
Foundational Social Skills (Ages 5–7)
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Name
*
First
Last
Email
*
Phone
*
Child's First Name
*
Child's Birthday
1. Can your child participate in a small group setting (4–6 children) for up to 60 minutes, with short movement or sensory breaks as needed?
Yes
No
2. Can your child follow simple directions in a group setting?
Yes
No
3. Does your child engage in adult-led or structured peer activities (e.g., simple games, crafts, or circle time) for a few minutes at a time?
Yes
No
4. Is your child able to participate in basic turn-taking games with adult support?
Yes
No
supports your weeks
5. Does your child tolerate changes in routine or activity transitions with minimal distress?
Yes
No
6. Does your child use words, phrases, or AAC to express basic wants, needs, or ideas?
Yes
No
7. Is your child interested in playing with or around other children (even if support is needed)?
Yes
No
8. Can your child engage in pretend play or imitate simple actions during play?
Yes
No
9. Does your child benefit from visual supports, modeling, or guided practice during social activities?
Yes
No
10. Are you able to commit to attending weekly sessions for 8 consecutive weeks (barring illness/emergency)?
Yes
No
11. Does your child currently have an Individualized Education Program (IEP) or receive services through the school district?
Yes
No
Not Sure
12. Does your child use any communication supports (e.g., AAC device, picture board, sign language)?
Yes
No
Occasionally
13. What are your goals or hopes for your child by participating in this group?
14. Are there any strategies, supports, or routines that work well for your child during group or structured activities?
15. Does your child have any specific fears, triggers, or behaviors we should be aware of to help them feel safe and successful in the group?
16. Anything else you’d like to tell us that would help us get to know your child better?
How did you hear about us?
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