Social Skills Group Intake Form

Child and Family History & References Form

Child’s Name:

Date of Birth:

Parent(s)/Guardian(s):

Email:

Phone:

Grade/School:

What are your child’s strengths & interests?

 

 

Does your child have a medical diagnosis and/or has he/she ever had a serious illness or injury?

____  No

____  Yes (please list)

 

Has your child received occupational or speech-language therapy?

____ No

____ Yes ______________________Start & end dates of therapy

 

Does your child have any behaviors we need to be aware of? 

____  No

____  Yes (please list)

 

Does your child have any allergies? 

____No

____Yes (please list allergies)

 

Can they have a snack during group?

 

Please provide one reference and contact number for previous group setting your child has participated in.

 

Name: ______________________________________        

Contact #/email_______________________________

I give permission for Jill McCarthy OT &/or Molly Filippini MA CCC-SLP to contact the reference listed above.

________________________________                        ______________

Parent or Legal Guardian                                                     Date