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Kid 2 Kid Screening Form, MENTOR Player             Our Village
Please fill out all areas prior to your screening
Email *
Today's Date *
Name of Child *
Gender *
Date of Birth *
Age *
Grade *
School *
Referred by:
Parent Names: *
Can a parent participate in our ONLINE Parent Ed Group, once per week? *
Home Address *
City and ZIP Code *
Phone number
Leave Voicemail?
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Text OK? *
Email OK? *
Social Play: Please describe your child's highest level of social play (ways the child might behave with other peers, not adults or siblings)
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Communication Style: Please describe your child's primary means of communication
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Play Preferences:
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What are your child's Special Interests and Special Affinities?
What are your child’s favorite games, activities and themes to play?
What sorts of games, activities and themes are difficult or non-preferred for your child to engage in?
Regulation (emotional or sensory): The ability to remain well regulated (ready and available for engagement and learning)
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Please describe what types of sensory stimuli might cause your child to become dysregulated (e.g. noise, light, touch, smell, etc.)
Please describe what types of emotional stimuli might cause your child to become dysregulated (e.g. transitions, change of routine, losing a game, difficulty sharing, etc.)
Please describe how your child expresses his or her dysregulation (cries, screams, hits, kicks, shuts down, withdraws, runs away)
Please provide any additional information that would help us best support your child in their peer play!
What type of classroom setting is your child in at school? (during traditional schoolyear) *
Medications: *
Allergies *
Would you like your child to participate in IN-PERSON small groups following CDC guidelines, VIRTUAL online groups, or whatever is best for their age and ability as determined by Our Village team? *
Please note: Our groups traditionally meet 1 hour per week for 8 weeks.  Then we take a break and start again.   For Scheduling, Please list any days and times your child is NOT available: *
Has your child ever participated in a Social Skills group before?  Where and when?  Was it successful, why or why not? *
What are your goals for your child in this group?   *
Comments or questions: *
May we add your email address to our newsletter so you can receive email updates on all our programs, events and resources shared through Our Village? *
Required
In addition, videos & photos are sometimes taken of your child during the group.  They may be used for marketing purposes on our social media and/or website, or used for trainings to help clinicians run the best groups possible
Thank you so much for your time and for your interest in the groups at Our Village!  We will review your application and send you a Calendar Link to schedule your free screening soon!   Please electronically sign your name here if you agree to do your free screening with us online, via a HIPAA secure platform, (we will send you a secure link soon).  We may ask to follow-up with an in-person screening if appropriate. *
A copy of your responses will be emailed to the address you provided.
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