Social Learning Groups Questionnaire
Parents Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Street Address
*
City
*
School and Grade:
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Languages spoken at home:
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Relevant medical diagnosis
*
Has your child's speech and language ever been evaluated either at school or elsewhere?
*
Please Select
Yes
No
If yes, please describe results (or provide report):
Has your child received speech therapy (either at school or elsewhere)?
*
Please Select
Yes
No
If yes, please describe their speech goals:
*
What are your child's social strengths? Do they have strengths in other areas (i.e., math, coding, art, cooking)?
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Does your child have any areas for growth in social communication (i.e., conversation skills, staying on topic, describing feelings)? Do they need help understanding social situations that may seem easy for their peers?
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Describe your child’s interactions with peers (i.e., do they engage with same-aged peers or older/younger peers or adults, do they seek out playing with peers, do they know when to join a group, etc.):
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Describe your child’s awareness and/or opinion of their social abilities (e.g., Are they aware of how others perceive them, do they think that they are perceived as “different” from their peers? If so, do they mind being perceived differently?)
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How does your child respond to everyday problems, such as changes in the schedule, peer conflicts etc. (e.g., large tantrums, very flexible with no reaction, etc.)? Do they have strategies to help them calm?
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Describe your child’s perspective taking skills (i.e., Do they read facial expressions appropriately? Can they identify other people’s feelings? Do they know the cause of what others feel?)
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What does your child do with unstructured time? Do they have any special interests, hobbies, etc.?
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Does your child participate in any extracurricular activities? Describe their motivation and engagement with extracurricular activities.
*
Please rate your child on a scale of 1-5 scale (5=Easy for them to independently do; 1= needs support most of the time) in each of these areas:
Social Communication
Rows
1
2
3
4
5
Asking questions about others
Making eye contact
Understanding the feelings of others
Understanding what people mean by
what they say, e.g., such as
understanding figurative language
or sarcasm
Showing empathy
Interpreting body language or facial
expressions
Revising message when
misunderstood
Understanding humor or uses
humor
Asks for help
Participation in a group
Listening
Maintaining conversations by making
comments or asking questions
Uses greetings and farewells
Apologizing
Telling wants, needs, or preferences
Attention/Organi-zation/Regulation
Rows
1
2
3
4
5
Paying attention to others
Turning in homework
Keeping backpack organized
Keeping school desk organized
Staying focused on preferred tasks
Taking responsibility for self
Responding to frustration
Understanding personal space
Flexible when plans change
Doing chores
Staying focused on non-preferred tasks
Compromising and/or negotiating
Personal problem solving
Understanding Consequences
Turning in Homework
Please verify that you are human
*
Thank you! We look forward to working with you and your child.
Do you have health insurance?
*
Please Select
Yes
No
If yes, please let us know your provider
Submit - enviar formulario
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