Social Skills Group Intake

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Client first name *

Client last name *

Client date of birth *

YYYY

Gender

Female

Male

Prefer not to say

Other:

Clear selection

Street address *

City, State, Zip *

Name and credential of diagnosing provider *

Primary diagnosis *

Additional diagnoses

Insurance company (NA if private pay) *

Insurance member ID (NA if private pay) *

Current medications with dosages *

Does your child currently attend school? *

Yes

If "Yes", name of school and grade

Does your child engage in any of the following behavior? *

Aggression

Self injury

Eloping

Property destruction

Other behavior that may prevent participation in a low provider to client ratio group setting

None

Required

Is your child toilet trained? *

Yes

Has your child ever been admitted to the hospital for a psychiatric, behavioral, or crisis situation? *

Yes

If "Yes", please summarize

How does your child communicate? *

Verbal communication

Gestural communication

Picture exchange

Other augmentative device

Other

Required

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