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Social Skills Intake Form
Step
1
of
6
- PARTICIPANT INFORMATION
16%
Parent Name
First
Last
Child Name
First
Last
Email
Phone
Child's Age
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Non-binary
Other
Does your child attend any school?
Yes
No
If yes, what grade:
If yes, where:
Does your child have any specific diagnoses?
Yes
No
Please list each diagnosis and when your child was diagnosed:
Approximately how many words does your child have in their vocabulary?
On average, how long are your child’s sentences (e.g., 2 words, 10 words, too many to count)?
Does your child use stereotyped language (e.g., repeating words/phrases out-of-context)?
Yes
No
Is your child able to use phrase speech (i.e., uses 2 or more words together) consistently/across contexts?
Yes
No
If your child is non-speaking, do they consistently use alternative communication methods (e.g., augmented communication devices, gestures, sign language)? If so, please describe:
Does your child respond to questions directed at them?
Yes
No
Does your child understand and respond to verbal directions?
Yes
No
Does your child seem to pay attention to what others are paying attention to (e.g., look up when someone enters the room, follow your gaze to an object)?
Yes
No
Does your child use their eye gaze/gestures to get you to attend to what they are interested in (i.e., look at you, then then to a toy, then back at you; point to a toy of interest while looking at/toward you)?
Yes
No
Does your child observe other children or seem aware of other children in their environment?
Yes
No
Does your child play near or next to other children, but without necessarily interacting with the other child(children)?
Yes
No
Does your child imitate you or other children?
Yes
No
Does your child seem interested in other children?
Yes
No
Can your child take turns in games and activities?
Yes
No
Does your child have intense, frequent and/or long-lasting meltdowns?
Yes
No
Do they engage in socially unexpected behaviors (e.g., impulsive behaviors, physical aggression)?
Yes
No
Is your child worried, nervous, fearful, and/or anxious much of the time?
Yes
No
Does your child have an excessive need for routine (e.g., gets stuck in routines, can be rigid, difficulty adapting to changes in routine)?
Yes
No
Does your child require 1-to-1 assistance?
Yes
No
Does your child have difficulty staying seated during group instructional time?
Yes
No
Does your child wander from the group or try to leave non-preferred areas without safety awareness?
Yes
No
Is your child receiving any outside services?
Yes
No
If so, what type and what frequency (e.g., occupational therapy, speech therapy):
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Email
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