Social Group Interest
Please complete this form so you can be added to the waitlist for summer social groups!
How did you hear about us and these groups?
Social Media/Online search
Therapist referral
Better Together Newsletter
Physician Referral
Other
What age social groups are you interested in?
Preschool 4-6
Young child 7-10
Pre-teen 11-13
Teen 14-17
Name of Child
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Diagnoses:
No diagnosis
Autism Spectrum Disorder
ADHD
Speech/Language Delay
Down Syndrome
Cerebral Palsy
Cognitive Impairment/Developmental Delay
Other
Behaviors: Please check behaviors that describe your child
Anxious
Withdrawn
Rigid
Impulsive
Verbally aggressive
Physically aggressive
Distracted/distracting to others
Oppositional
How does your child communicate?
Non verbal
Gestures
Single words
Short phrases
Sentences
Engages in conversations
Other
What do you hope to gain from the social group?
Conversational skills (greetings, initiates, eye contact, engaging, staying on topic, interrupting)
Making friends
Play skills (turn taking, initiating, sustained play, following rules, sportsmanship)
Problem solving (conflicts, apologizes, asking for help, teasing, anger management)
Other
Caregiver/Parent Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Best way to contact you
Email
Phone
Other
Best time for group
Morning
Afternoon
Either time
Other
Submit
Should be Empty: