Intake Form for Communication Works

Social Learning Groups Intake Form

Contact Information

Personal Information

Age:
DOB:
Diagnosis (if any):
School:	Special Ed Regular Ed
Grade Level:	Classroom Aide: Yes No	% of Day
SLP services (therapist/frequency):
SLP addressing:	Client of the Regional Center of the East Bay (RCEB): Yes No
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? Yes No	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.