Mitchell's Place Fall Social Skills Group Interest Form
Mitchell's Place is offering a fall social skills group for children in 3rd - 5th grade. Children must be able to communicate independently and not require 1:1 behavioral or communication assistance. If you are interested in participating, please submit this form and a provider will be in contact with more information.
Participant Name
*
First Name
Last Name
Participant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Caregiver Name
*
First Name
Last Name
Contact Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Please share what grade your child will be in and what school they are currently enrolled in.
*
Does your child receive school services?
*
Yes
No
Please share your child's medical diagnosis.
*
Does your child take any medications? If so, what are they?
*
Please describe your child's language abilities:
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Answers questions, but does not participate in "back and forth" conversation.
Frequently is "stuck" on a topic and only wants to discuss it.
Uses complex sentence structure.
Uses simple phrases and sentences.
Please describe your child's current social skills.
Does your child have any outbursts or meltdowns due to anger, frustration, or sensory overload? If so, what do they look like?
*
Is your child typically compliant with adult demands? (If no, what are some strategies that are usually successful?)
*
Do you have any other questions or comments?
How did you hear about us?
Submit Registration
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