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Social Group Interest Form
Thank you for your interest! This packet helps us understand your child’s needs and ensure the best possible group placement.
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Client Full Name
Your answer
Date of Birth
Your answer
Age
Your answer
Gender
Male
Female
Prefer not to say
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Diagnosis (if any)
Your answer
Language(s) spoken
Your answer
Parent/guardian Information
Your answer
Relationship to client
Your answer
Phone number
Your answer
Email address
Your answer
Address
Your answer
Emergency Contact, Relationship to Client & Phone Number
Your answer
Allergies
Your answer
Seizure History
Yes
No
Clear selection
Current Medications
Your answer
What type of insurance does your child have? (if any)
Your answer
Any aggressive/self-injurious behaviors?
Yes
No
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How does the individual primarily communicate?
Vocal
Sign Language
AAC
Gestures
Other:
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Does your child currently receive therapy?
Yes
No
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Current IEP or school accommodations? (if yes, please provide a copy if available)
Your answer
Has your child participated in social groups before?
Yes
No
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What are your child's strengths in social settings?
Your answer
What are current challenges (e.g., turn taking, initiating play)?
Your answer
What goals do you have for your child in this program?
Your answer
Can your child participate in a group setting with minimal 1:1 support?
Yes
No
Unsure
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Is your child toilet-trained?
Yes
No
In-Progress
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