Summer Camp Social Skills Screening Form
Please answer the questions below. Give examples when appropriate. With more information we will be better able to quickly provide an answer on the appropriateness of the group for your child's needs.
Email address *
Your Name *
Your answer
Child's Name *
Your answer
Child's Age *
Your answer
County and State of Residence *
Your answer
Who is your insurance provider?
Your answer
Does you insurance provider cover ABA services
Are you interested in the after- school program or Summer camp? *
Is your child verbal? *
For children ages 4-10; which days do you prefer to have after school sessions?
Describe your child's educational placement? (general education, special education, etc.)
Your answer
How does your child do in group settings? Our ratio for the Social Skills program is 1 staff:5 clients. *
Your answer
How does your child interact with peers? Give examples of interactions. *
Your answer
How would your child respond if a peer asked "what is your favorite color?" *
Your answer
What does your child do if he/she is not able to get what they want? Give specific examples of what the behavior looks like. *
Your answer
What happens when your child is in a larger group setting (10 or more children)? *
Your answer
Will your child be able to arrive within the drop off window between 4:00-4:30PM up to twice a week? *
If neither of the above locations are preferable, please indicate your desired location for group:
Your answer
How did you hear about our Social Beginnings Program?
Your answer
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