Social Skills Group Intake Form

Child and Family History & References Form

Child’s Name:

Date of Birth:





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? 


____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