Social Skills Intake Form - The Help Group

Step 1 of 6 - PARTICIPANT INFORMATION

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Parent Name

First Last

Child Name

First Last

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

If yes, what grade:

If yes, where:

Does your child have any specific diagnoses?

Yes

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

Is your child able to use phrase speech (i.e., uses 2 or more words together) consistently/across contexts?

Yes

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

Does your child understand and respond to verbal directions?

Yes

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

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

Does your child observe other children or seem aware of other children in their environment?

Yes

Does your child play near or next to other children, but without necessarily interacting with the other child(children)?

Yes

Does your child imitate you or other children?

Yes

Does your child seem interested in other children?

Yes

Can your child take turns in games and activities?

Yes

Does your child have intense, frequent and/or long-lasting meltdowns?

Yes

Do they engage in socially unexpected behaviors (e.g., impulsive behaviors, physical aggression)?

Yes

Is your child worried, nervous, fearful, and/or anxious much of the time?

Yes

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

Does your child require 1-to-1 assistance?

Yes

Does your child have difficulty staying seated during group instructional time?

Yes

Does your child wander from the group or try to leave non-preferred areas without safety awareness?

Yes

Is your child receiving any outside services?

Yes

If so, what type and what frequency (e.g., occupational therapy, speech therapy):

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