PARENT   INTAKE   FORM

Parent Name:____________________________________	Phone: H______________________
								            C______________________

Address: ______________________________________________________________________

Child’s Name: ____________________________________ DOB: ___________Age:_________

Allergies:_________________________________ Special diet:__________________________

Siblings Names & ages: ___________________________________________________________
(please list the names of any siblings that you might like to enroll for free as our typical peer models)

Diagnosis:_____________________________________________________________________(Please list all diagnosis as they pertain to Speech  - OT-  PT related issues)

1) My number one reason for placing my child into a social skills group is ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2) My hope for my child in having them participate in group is to see improvement in ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3) Some things that help my child regulate their behavior/communicate/increase attention are
(Brushing, swinging, spinning, augmentative device, PROMPT, time out, sensory diet) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please use the scale of 1-10 with 10 being the easiest and the child needs no help with this area and 1 being the hardest and the child needs a lot of help with this area. 

Eye contact					1   2   3   4   5   6   7   8   9   10

Initiating conversation			1   2   3   4   5   6   7   8   9   10

Responding to peers				1   2   3   4   5   6   7   8   9   10

Asking questions				1   2   3   4   5   6   7   8   9   10

Answering questions				1   2   3   4   5   6   7   8   9   10

Maintaining 4-7 conversational turns		1   2   3   4   5   6   7   8   9   10

Co-play with a peer				1   2   3   4   5   6   7   8   9   10

Sharing					1   2   3   4   5   6   7   8   9   10

Turn taking					1   2   3   4   5   6   7   8   9   10

Voicing opinion				1   2   3   4   5   6   7   8   9   10

Respects others space				1   2   3   4   5   6   7   8   9   10

Follows directions				1   2   3   4   5   6   7   8   9   10

Additionally I would like you to know that my child is
(Please describe your child’s personality -likes/dislikes etc...)
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