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/Caregiver Name *
Your answer
Email *
Your answer
Parent/Guardian Phone Number
Your answer
Date form filled out: *
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Child's Name
Your answer
Child's Age
Your answer
Child Birth Date
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Client Gender
Diagnosis (if any)
Your answer
Classroom Placement
Communication
Independence
Toileting
Check behaviors that have occured over the last month
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.
Your answer
My child's interests include:
Your answer
My child does not enjoy:
Your answer
Describe your child's interest in other peers/forming friendships:
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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. *
Required
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?
Your answer
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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