Social Group

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Social Group - 2025

Thank you for checking out our offerings at Midsouth Therapy Group! Please complete MTG's Social Group interest form below.

This group meets from 4:00-5:00 PM on Tuesdays.

Note that completion of this form does not guarantee your child a spot in our social skills group at this time. Our team will be in touch with you if your child is a strong candidate for this group.

Please contact therapy@midsouththerapygroup.com with additional questions.

Child's name *

Child's date of birth *

YYYY

Child's grade *

Parent/caregiver name(s) *

Phone number *

Email address *

Does your child have any known diagnoses? If yes, please list.

Does your child have any allergies or dietary restrictions?
*

Does your child currently receive any therapy services? Check all that apply.

Occupational therapy (OT)

Speech-language therapy (ST)

Physical therapy (PT)

Behavioral therapy (ABA)

Other:

Can your child remain seated at the table and attend to presented tasks? *

Yes

Does your child follow simple directions easily? *

Yes

Check all that apply regarding your child's conversational skills. (Check the box if your answer is "always" or "often.") Does your child... *

Appropriately begin/end conversations (face-to-face, via phone, etc.)

Appropriately take turns in conversations with others, including listening as much as talking

Maintain conversation topics (vs. changing topics at random)

Talk about preferred topics for an appropriate length of time (vs. oversharing)

Avoid use of repetitive/redundant information

Willingly discuss topics NOT of interest to him/her

Ask for and respond to requests for clarification during conversations

Use appropriate strategies for gaining attention

Use appropriate strategies for responding to interruptions and interrupting others

Understand and demonstrate humor and jokes

Respond appropriately to introductions and introducing others

Participate/interact well in structured group activities

Participate/interact well in unstructured group activities

None of the above

Other:

Required

Check all that apply. (Check the box if your answer is "always" or "often.") Does your child... *

Accurately give and appropriately ask for directions

Give/ask for reasons and causes for actions/conditions/choices

Ask for help

Offer help

Give and respond to advice/suggestions

Ask for permission when required

Regulate emotions when disagreement occurs

Apologize and accept apologies

Respond appropriately when asked to change his/her actions (by accepting/rejecting)

Respond appropriately to teasing, anger, failure, or disappointment

Offer/respond to expressions of affection and appreciation

Accurately read social situations and react/respond accordingly

Understand posted and implied group/school rules

None of the above

Required

Check all that apply regarding your child's nonverbal communication skills. (Check the box if your answer is "always" or "often.") Does your child... *

Correctly interpret others' facial expressions

Respond to greetings and farewells

Accurately interpret others' tone of voice

Demonstrate appropriate facial expressions

Use appropriate body language

Use intonation appropriately (pitch, inflection, tone, or cadence)

Adjust body distance according to the situation (respecting personal space)

None of the above

Required

Please include any other pertinent information here.

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