Social Skills Registration Form
Help us learn more about your child!
Email address *
Parent name:
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Child's full name:
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What does your child like to be called?
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Child's age and birthday:
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Parent phone number:
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Preferred mode of contact:
Emergency contact #1 and phone number:
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Emergency contact #2 and phone number:
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Food allergies: *
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Other allergies *
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Specific sensory issues? *
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Which aspects of your child's social skills development are you most concerned about? *
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What would you like your child to learn in a social skills intervention program?
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What are some of your child's current strengths and weaknesses? This can be related to social interaction as well as general functioning at home, school, etc.
Your answer
What are some of your child's general interests?
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Describe features of your child's closest friendship or peer interaction. For example, his friends tend to be leaders and my child tends to follow their lead of play or my child often plays amidst other children but rarely seeks playing with others
Your answer
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