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Social Language Groups Intake Form

Contact Information

Client Name
Parent/Guardian Full Name Parent/Guardian Full Name
Address
City
State
Zip
E-mail
Home Phone Cell Phone
Referred By

 

Personal Information

Age:
DOB:
Diagnosis (if any):
School: Regular Ed Special Ed
Grade Level: Aide:   Yes  No% of Day
SLP services (therapist/frequency):
SLP addressing:
OT services (therapist/frequency):
OT addressing:

 

Communication Level

At what level does your child communicate?       Words   Phrases   Sentences   Converstions
How would you rate your child's Eye contact?      Good    Fair    Poor
Greetings?         Good    Fair    Poor

 

Social Situation Questions

Can your child handle a group setting (4-6 kids) with 1 therapist and structured lessons?
Can your child do table top activities for 10 minutes?    YesNo 20 minutes?     YesNo
30+ minutes?  YesNo
Does your child display any negative behaviors (e.g.) verbal or physical aggresson towards other students?

 

What are your main reasons for having your child participate in social language groups?

Student Availability

Please indicate by "X" which time and date slots your child is NOT available to attend a language group.

  Monday Wednesday Friday
2:00-2:30pm
2:30-3:00pm
3:00-3:30pm
3:30-4:00pm
4:00-4:30pm
4:30-5:00pm
5:00-5:30pm
5:30-6:00pm
6:00-6:30pm
6:30-7:00pm

 

Communication Works
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