Secret Agent Society (SAS) Social Skills Group Interest Form
Please take the time to fill out this form. Upon receipt, families will be contacted.
SAS is for those ages 8-12.
Email address *
Child's Name *
Your answer
Child's Date of Birth *
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DD
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Parents' Names *
Your answer
Phone Number *
Your answer
Address *
Your answer
Which SAS program are you interested in:
What school does your child attend? What grade? *
Your answer
How did you learn about about our SAS Program? *
Your answer
The SAS program is a parent-assisted intervention for 8-12 year olds that are having difficulties making or keeping friends. Is the child in this age range and would this program be of interest to his/her family? *
There is a parent component of the SAS Program which requires one parent to attend on a consistent basis. Another parent is welcome to attend, but for continuity, parents may not trade-off attending. Would at least one parent be available to consistently attend the program with their child? *
There are separate parent and child sessions that meet at the same time for 90-minutes each week over a 12 week period. Parents are taught how to help their child make friends by acting as social coaches outside of the group. Would parents agree to complete all homework assignments? *
Does the child want to have friends and learn new strategies? Would s/he be motivated to learn how to make new friends and attend the class? 1= extremely resistant, 5= Is open to being helped and wants desperately to improve. *
What are the child's favorite activities or special interests? (e.g., Star Wars, board games, video games, Minecraft, etc.) *
Your answer
What road block(s) does the child have making friends? Please check off all options that apply. *
Required
Does the child have any type of psychological or medical diagnosis? Please check off all options that apply. *
Required
Is the child taking any prescription medications right now? If yes, please list medications. *
Your answer
How severely affected is the child's communication? This will help us understand his/her language and conversational abilities. 1= Uses echolalia, brief sentences or single words, needs frequent adult support, very limited verbal expressive abilities, 5=Mainstreamed in advanced academic classes, socially awkward, trouble making/keeping friends *
What educational classroom setting is the child currently placed in? *
Academically, is the child taking any classes below grade level? *
Academically, my child has a(n) : *
Required
Is the child currently receiving any services at or outside of school? *
If yes, please indicate which services (i.e., speech-language, social skills, behavioral services, occupational therapy, counseling therapy, etc.)
Your answer
Does the child have any aggressive behavioral difficulties at home or school? Please check off all options that apply. *
Required
Does the child have a group of friends at school? *
Does the child have get-togethers with peers or have friends come over? *
Any other questions or comments? *
Your answer
A copy of your responses will be emailed to the address you provided.
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