Social Skills Group Screening Form 
Welcome! We are excited that you are interested in having your child participate in our Social Skills Group.  This will be run by experienced clinicians and a "Behavior Coach" at the private practice of Stefanie Rushatakankovit, Licensed Educational Psychologist and Board Certified Behavior Analyst. 


Completing this form is the first step of our screening process- All of your responses will be kept CONFIDENTIAL.  Contact us for a brief consultation if you prefer.  

Spaces are limited; group members will be accepted based on both date of submission of this form, completion of the screening process, and appropriate fit for the current group.   

We also form groups based on interest, so we encourage you to complete this so we may potentially form a group.

Once you complete this form, you will receive confirmation via e-mail or phone on next steps.  Please contact us if you have any questions!  Feel free to reach out to 

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Email *
Form completed by (Name & relationship):
Child's First & Last Name
Child's Gender
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Child's pronouns
Child's Date of Birth
Age of Child
Current Grade at School (if completing this in between school years, choose the "rising" grade for the fall).
Name of Child's School (optional)
Are there any current custody arrangements for your child?  
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Select which group you are interested in your child joining.  Final groupings will be determined by CPEG. We group based on similar ages and needs. *
Parent/caregiver will be expected to join the last 5 or 10 minutes of each group to hear about the skill taught and tips on how to help their child practice for that week. 

*For the PEERS GROUP ONLY (6th-12th grades): at least one parent is expected to join the weekly concurrent parent group (held virtually on a different day or in-person at the same time, TBD).  Ideally, this will be the same parent attending.  

NAME and Email address of the Participating Parent/Caregiver (more than 1 is fine)

(Skip if not sure yet)
Inclusion Criteria: Check ANY that apply for your child: *
Exclusion Criteria:  Check ANY that apply for your child: *
Current Social Problems: Check all that apply
Of your concerns above, what are your top 3 concerns?
What are 2-3 skills you hope your child will learn from or improve in with this group? 
Does your child have any clinical diagnoses or disorders? (e.g. anxiety, ADHD, ASD, dyslexia, learning disability, etc) This information is kept confidential and for planning purposes
If your child has a diagnosis, is he/she/they aware of it?
List a few of your child's interests and what motivates them. We will try to incorporate this in our planning.
Special accommodations: if you anticipate your child will have any specific accommodations in order to participate in the group, please describe:
Please specify any food allergies, medical, or health conditions that may impact your child's participation in the group:
Please specify any medications your child is being currently prescribed and taking (optional):
KIDS' GROUPS ONLY (ages 4-11): We use a positive reinforcement system where your child may earn a small prize or snack at the end of each session and/or group. If your child has any food allergies, or you have any concerns about this, please describe below. 
KIDS' GROUPS ONLY (ages 4-11):We may require a brief video meeting with you and your child as part of the screening process. We also offer this for children who might be hesitant, nervous, or have questions about the group.  Please let us know if this would be something you would be interested in.
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Feel free to add any other information you would like us to know.
We will confirm the final group members and reach out to you if we decide the current group may not benefit your child.  If that happens, do you allow us to keep your child on our waiting list for the next social skills group?      *
How were you referred to us?
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Name of person who referred you so we may thank them:
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