Keene Perspectives Social Learning Group Interest Form
Hello! This initial interest form is the first step in the intake and enrollment process for social learning groups at Keene Perspectives. The information obtained here helps the team determine whether or not your child would be a good candidate for the program at this time. Upon receipt and review of the form, we will follow up with you to discuss your family's needs in more detail and review the next steps.

We will be adding new group times and age groups over the course of 2018.

Spring Session is scheduled to begin the last week of April and run through the first week of June.

Email address *
Date Form Completed *
MM
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DD
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Child's Name *
First and last name
Your answer
Child's Age *
Age
Your answer
Child's Grade *
Grade
Your answer
Child's Gender *
Gender
Child's Birthdate *
Birthdate
MM
/
DD
/
YYYY
Parent/Guardian Name *
First and Last name
Your answer
Parent/Guardian Phone Number *
Phone Number, please include area code
Your answer
Town of Residence *
What town do you live in?
Your answer
Enrollment Status at Keene Perspectives *
Diagnosis (if any) *
Your answer
Classroom Placement *
Required
Communication *
Required
Level of Independence *
Toileting *
Challenging Behaviors *
Required
Please identify (3) three top priorities for skills that you would like to see addressed in social group. Please choose targets that you feel will have the most impact for your child and family. *
Your answer
My child's interests include: *
Your answer
My child does NOT enjoy: *
Your answer
Describe your child's level of interest in other children/forming friendships? *
How did you hear about Keene Perspectives? *
Required
Any additional questions or comments for our team? *
Your answer
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