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Virtual Teen Social Skills Group(Sept 14-Nov 2) Intake Form
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Email
*
Your email
Name of Participant
*
Your answer
Age of Participant
Your answer
School District or Adult Program Participant Attends
Your answer
Is the participant willing to participate in group?(expresses interest in making and keeping friends)
Yes
Participant is resistant but will actively participate
Resistant but these are important skills that the participant must learn
No
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Name of Parent
Your answer
Parent Phone Number
Your answer
How did you hear about our Social Skills Group?
Your answer
Background Information (click all that apply)
Autism Spectrum Disorder (ASD)
Intellectual Disability (ID)
Emotional Disability (ED)
Social Pragmatic Language Disorder
Does not participate often in get togethers with peers
Argumentative/disruptive/tantrums
History of bullying/teasing behaviors
Other:
Any other important information for Deirdre to know about the participant?
Your answer
Payment of $330 ---Payment to secure your spot---Venmo: Deirdre-Flores-SLP
I agree the payment policy
Other:
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A copy of your responses will be emailed to the address you provided.
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