Be Social Kids Intake Form

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Please complete this form in its entirety. Our team will thoroughly review it to determine if your child may be a good fit for one of our existing social groups. Thanks so much for taking the time!

Child's Name: *

Date of Birth: *

Parent/Guardian Full Name(s): *

Address: *

Preferred Phone Number: *

Preferred Email(s): *

Please let us know if you were referred to CCL and by whom:

Pediatrician Name and Phone Number: *

Language(s) Spoken at Home: *

Does your child have any significant medical history that we should be aware of, such as frequent colds/hospitalizations/other medical issues? *

Does your child have a formal diagnosis/es? If so, please list. *

Is your child taking any medication? If so, please list.

Does your child have any food allergies? If so, please list.

Is your child on any special diet or dietary restrictions? If yes, please list.

Sensory History (check all that apply)

Fussy infant

Difficult to calm

Very active

Sensitive to textures

Toe walking

Separation difficulties

Difficulty getting or staying asleep

Resistance to cuddling/being held

Poor eye contact

Sensitive to sounds

Sensitive to lights or movement

Anxiety

Perseverative

Educational History:

Current School and Grade:

Program (if applicable) (ex: PEP, Learning Center):

Current IEP or 504 plan? If so, please provide a copy. *

Yes

Current Services:

OT/PT

Speech/Language

Resource/special education academic and/or behavioral support

1:1 Aide

In reading/literacy, my child is generally performing: *

Below Grade Level

On Grade Level

Above Grade Level

In mathematics, my child is generally performing:

Below Grade Level

On Grade Level

Above Grade Level

Clear selection

Social Learning:

Please list strengths and weaknesses your child has in the area of social skills:

Your child's social strengths:

Your child's social challenges: *

Please list three goals you have for your child in the area of social skills. *

What are some of your child's interests/activities within and outside of school? *

Are there any situations, relevant to our group, which may upset or agitate your child? If so, please explain.

Does your child play with children his/her own age? If no, what age children is he/she most comfortable with? *

Does your child seek friendships with peers? *

Yes

Has your child ever participated in a social skills/social pragmatic group before? If yes, please explain.

In order to assist the Speech-Language Pathologists with getting a complete profile of your child’s strengths and weaknesses, please check off any and all areas which you feel may currently apply to your child.

Auditory Processing:

Does not listen carefully to directions

Sometimes misunderstands what is said

Needs extra time to respond to questions

Background noise makes following verbal instructions even more difficult

Says “huh” or “what” in response to questions

Does not respond to name when called

Listening:

Has difficulty paying attention

Has difficulty following spoken directions

Has difficulty remembering things people say

Has difficulty understanding what people are saying

Has difficulty listening without repetitions

Has difficulty understanding the meaning of words

Has difficulty understanding new ideas

Has difficulty looking at people when talking or listening

Has difficulty understanding facial expressions, gestures, or body language

Attention:

Often fails to give close attention to details/makes careless mistakes

Often has difficulty sustaining attention in tasks or play activities in school and at home

Has difficulty organizing tasks and activities

Often loses things necessary for tasks and activities (e.g. toys, assignments, school supplies)

Fidgets with hands or feet or squirms in seat

Leaves seat in classroom on in other situations in which remaining seated is expected

Easily distracted

Often blurts out answers before the questions have been completed

Has difficulty awaiting turn

Daydreams and/or is inattentive

Speaking:

Has difficulty answering questions people ask

Has difficulty answering questions as quickly as other students

Has difficulty asking for help when needed

Has difficulty asking questions

Has difficulty using a variety of vocabulary words when talking

Has difficulty expressing thoughts

Has difficulty describing things to people

Has difficulty getting to the point when talking

Has difficulty putting events in the right order when telling stories or talking about events

Has difficulty using appropriate grammar when talking

Has difficulty using complete sentences when talking

Talks in short, choppy sentences

Has difficulty expanding an answer or providing details when talking

Has difficulty having a conversation with someone

Has difficulty talking with a group of people

Has difficulty saying something another way when someone doesn’t understand

Has a tendency to try and dominate the conversation

Discusses only preferred topics, without awareness or checking in whether other person is interested/listening

Word Retrieval:

Knows the word (s)he wants to say, but cannot think of it

Has difficulty remembering the names of people, places, objects that he/she knows

Substitutes words with a similar word/by describing the word by category, function, or what it looks like

There is sometimes a long delay when he/she cannot think of the word

Makes false starts/ revisions when relating an experience (e.g. “we were…Bob and I went")

Uses time fillers when trying to think of a word (e.g., um..er..um..computer)

Gives too much information and includes irrelevancies

Behaviors:

Motivated

Impulsive

Rigid

Withdrawn/Shy

Outgoing

Anxious

Tends to dominate conversations

Competitive

Oppositional

Physically aggressive

Verbally aggressive

Externally distracted

Aloof/Internally distracted

Is there anything else you would like us to know about your child when considering them for a social group? Thank you for filling out this form! We appreciate it.

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