MBG Social Language Group Intake Form 2024

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Milestones Social Skills Group Intake Form 2024

Social Language Groups will be offered at our Birmingham and Springville Offices for 60-90 minute sessions, weekly. Specific dates and times will be announced in May, 2024, based on parent/caregiver preference and peer groupings.
Social Group Skills Taught

Joint Attention, Social Play, Self-Regulation, Social/Emotional Responding, Conversation, Expected Behaviors in Social Situations, Nonverbal Social Language, Making and Strengthening Friendships and so much more! We use a variety of evidence-based curricula and individualize social skills goals for each learner. Some of our programs include: PEERS, Everyday Speech, Accept-Identify-Move (AIM), ABLLS-R, AFLS, and Socially Savvy.
Preferred Location:
Name of Student

First NameLast Name
Student's DOB
What grade is the child currently in?
Does your child present with any of the following behaviors? We gather this information to determine if our Social Language Group is an appropriate fit for them, or if we need to discuss other options such as ABA therapy and/or Social Behavior Groups.
Please select your preferred days and time frames (all that apply)
Cost

We accept insurance for current Speech/Language Therapy clients of Milestones. PRIVATE PAY: 1 hour sessions with our SLPs is $60/session. 1.5 hour sessions with ur SLPs is $90/session.
Name of Parent/Guardian

First NameLast Name
Parent's Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
What is the Student's primary language?
Diagnoses ex; Autism, Speech Delay, etc
If no diagnosis, type N/A. Insurance will not cover ABA without a formal Autism diagnosis and report
Parent/Guardian Concerns
Does your child receive ABA therapy? If so, please list the days/times.
What are some of your child's favorite toys/interests/activities?
Social Skills Screener
Identifying Feelings: Given real-life pictures or video scenes depicting specific emotions, will the learner receptively/expressively identify/label four basic feelings (i.e., sad, mad, happy, scared) by interpreting character’s facial expressions?
Changing the Channel on Feelings (Coping with Tough Emotions): When strong emotions arise such as jealousy, disappointment, frustration, and/or embarrassment, does the student independently utilize coping strategies (i.e., taking a break, positive self-talk, deep breaths) to stay calm and minimize adult intervention?
Keeping an Open Mind: Does the Learner accept a new plan or idea without displaying behaviors?
Staying Calm: When faced with an upsetting or frustrating event, in a small/large group/classroom setting, does the learner will use calm-down strategies (i.e., taking a break, positive self-talk, deep breaths) to return to a calm state?
Using your Self-Controller (Keeping Self-Control): Does the learner maintain control when stressful triggers arise (i.e., running late, not having needed supplies, being denied access to a highly reinforcing item)?
Switching Tracks (Handling Change): Does the learner accept changes in his/her schedule or plan utilizing the strategies without opposition or challenging behaviors?
Keeping Hands to Yourself: Does the Learner show self-control of their body by avoiding the use of physical behaviors (i.e., hitting, kicking)?
Ignoring Others' Behavior: Does the Learner practice self-management by ignoring classroom/peer conflict (i.e., remaining in seat, not getting involved)?
Accepting a Consequence: Does the Learner accept a consequence without displaying behaviors (i.e., yelling, crying, kicking, etc.)?
On Purpose Plan (Accidents vs. Intentional): Does the Learner will use perspective-taking skills to accurately determine whether others’ actions are purposeful or accidental?
Asking Others to Play: Does the Learner initiate play (i.e., brings over toy or activity, requests to play) with at least 1 other peer?
Playing with Others: Does the Learner engage in age-appropriate play with others by taking turns/staying engaged for at least 5 minutes playing cooperatively?
Being a Good Sport: Does the Learner remain calm and display good sportsmanship throughout an entire game?
Classroom Routine: Does the Learner follow familiar classroom routines (i.e., entering a classroom, sitting with the group, walking in the halls, etc.)?
Following Directions: Does the Learner follow single/multi-step adult verbal/visual directives in a small/large group setting?
Listening in School: Does the Learner demonstrate listening skills by repeating adult directives/responding to adult prompting accurately during small/large group lessons ?
Staying Quiet in Class: Does the Learner maintain a quiet voice when they raise their hand and wait to be called on by an adult?
Asking for Help: Does the Learner ask an adult for help by utilizing conventional communication (i.e., verbally, picture symbols, sign)?
Working with a Group: Does the Learner appropriately participate in small/large group activity (i.e., play or academic) by compromising, allowing others to share ideas, and accepting others’ plans?
Showing Respect: Does the Learner act respectfully towards adults and peers by using kind words, recognizing others’ ideas and opinions?
Tuning In (Observing Yourself and Others): Does the Learner will maintain social awareness by observing their environment and others around them to adjust their own behavior ?
Understanding Others' Point of View: Given a hypothetical and/or real social situation, does the learner describe the likely perspective, intentions, or feelings of at least 1 involved individual ?
Empathy Essentials: Given a hypothetical and/or real social narrative, does the learner demonstrate empathy by showing care, concern, or expression of feelings ?
Starting a Conversation: Does the Learner will initiate a conversation with a peer/adult (i.e., getting listener’s attention, selecting a conversation partner, choosing the right time to start a conversation) ?
Conversation Stoplight (Knowing When to Talk): Does the Learner take turns during a conversation (i.e., listens while others are talking, speaks while no one else is speaking) ?
Conversation Drivers & Stoppers (Maintaining a Conversation): Does the Learner maintain a reciprocal conversation by asking questions, making connected or related comments, and acting interested for at least 4 conversational exchanges?
Conversation Share (Knowing How Much to Talk): Does the Learner engage in an age-appropriate conversation by monitoring their own time spent talking ?
Ending a Conversation: Does the Learner end a conversation before walking away or changing their focus?
Making Connected Comments (Staying on Topic): When engaged in a conversation, does the learner will make related comments or ask questions for 4 conversational exchanges ?
Topic Radar (How to Pick the Topic): Does the Learner initiate a conversation with a familiar peer or adult based on past knowledge of their conversation partner’s preferred topic(s) ?
Topic Surfing (Shifting the Topic): When engaged in conversation, does the learner shift the topic of conversation using a transitional statement or question to maintain the conversation ?
Think It or Say It (Using a Filter): Given hypothetical social situations, does the learner identify whether a statement is best as a ‘thought’ or ‘expressed words’ ?
The Two W's (Making Small Talk): Given hypothetical social situations, does the learner produce responses consistent with ‘making small talk’ ?
Direct and Indirect Language: Given hypothetical social situations, does the learner identify whether a ‘direct’ or ‘indirect’ response is warranted ?
Attendance Policy, Financial Agreement, & Consent to Treat
PRIVATE PAY FEES

1 hour sessions with our SLP in Birmingham are $60 | 1.5 hour sessions with our SLP or Behavior Analysts in Springville are $90 per session.
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Your Signature Agreeing to Payment Terms Above
Your Signature Agreeing to Give Consent for Treatment Described Above
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SIGN UP FOR THIS SERVICE HAS EXPIRED. DO NOT COMPLETE THIS FORM. EMAIL OUR OFFICE FOR INFO ON ABA, SPEECH, and OT THERAPIES at therapy@milestonesaba.com

Milestones Social Skills Group Intake Form 2024

Social Group Skills Taught

Cost

Social Skills Screener

Attendance Policy, Financial Agreement, & Consent to Treat

PRIVATE PAY FEES