Peer-Projects: Questionnaire for Social Skills group


Questionnaire for Social Skills group

If you're interested in being a part of our group, please fill out intake form below

Child's name:	Date of Birth: (Ex. mo/dy/yyrr)
First Name: Last Name:	(Ex. 10/22/1995)

Parents'/Caregivers' Names: If address' are the same, only enter one.
First Name: Last Name:
Address: City: State: Zip Code:
Home Phone: Cell Phone: Email:

First Name: Last Name:
Address: City: State: Zip Code:
Home Phone: Cell Phone: Email:

Health Insurance Provider:

How did you find out about Peer Projects?

Where is your child in school?

What is the current support in place for your child in that setting? (i.e., integrated classroom? 1:1 aide? Therapies? Etc.).

Describe the type of peer experiences your child has had so far (e.g., typical peers, playdates, siblings, group experiences, etc.).

Have these been successful? In what ways?

Describe some of the difficulties you have observed your child experience with peers.

Describe your child's language skills (i.e., talking in phrases? Sentences? Conversational? What kinds of things does your child understand? Not understand?).

Does your child use any behaviors when he/she feels stressed or overwhelmed? What are the best strategies to use when addressing these?

What would you like your child to gain from this type of group experience?

Is there anything else you would like me to know about your child?