Social Skills Group Enrollment
Hello! This application is the first step in the intake and enrollment process for social skills groups. 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.
Parent/Guardian Phone Number
Date form filled out:
Child Birth Date
Diagnosis (if any)
No formal mode of communication
alternative communication (sign, PECS, communication device)
requires constant 1:1 support
may require 1:1 support depending on activity
does not require support in a small group
may require minimal support to make sure all steps are done or to locate bathroom
is not toilet trained
Check behaviors that have occured over the last month
aggression toward peers
elopement (leaving area without permisison)
loud vocal stereotype
no behavior of this kind
Identify three (3) 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 your family.
My child's interests include:
My child does not enjoy:
Describe your child's interest in other peers/forming friendships:
Preferred Time (times are determined per age groups and may change depending on need per quarter/semester). Groups are 1.5 hours in length. Check as many as apply.
Developmental Playgroup (2-5) Friday 12:00-1:30PM
Developmental Playgroup (2-5) Friday morning option coming soon. Please check if this is of interest.
Grade K-2 Wednesday 4-5:30PM
Grades K-2 Friday 2:15-3:45PM
Grades 3-6 Tuesday 4-5:30PM
Grades 3-6 Thursday 4-5:30PM
Teens Monday 4-5:30 PM
Teens Friday 4-5:30 PM
Are you interested in parent groups while your child is in session?
Any additional questions or comments about your child that will be helpful for our team?
Some insurances cover social skills groups (ASD diagnosis or ABA referral from Center of Excellence for Medicaid plans). Please fill out the insurance verification form if you would like us to check your benefits. Private pay cost for social skill groups are due prior to sessions.
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This form was created inside of Focused Behavior Solutions, LLC.