Social Skills Inquiry
Child's Name
First Name
Last Name
Child's date of birth
-
Month
-
Day
Year
Date
Level of ASD Diagnosis
Please Select
Level 1
Level 2
Level 3
Does your child have any other diagnoses? If so, please list
Parent Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
What social skills does your child need assistance with?
conversation and communication
relationships and peer interaction
problem solving and conflict resolution
perspective taking and empathy
daily life and independence
what time would work best for you?
morning
afternoon
after school (3-5)
All of the above
You would be required to do an initial appointment and assessments for your child, is this something you would be able to do?
yes
no
We ask that you commit to at MINIMUM 6 months to 1 year of services based off of what your insurance approves. Is this a commitment you can make?
yes
no
We ask that you commit to at MINIMUM of 1 parent training with BCBA per month. Is this a commitment you can make?
yes
no
Would you be interested in a GROUP parent training with a BCBA and other parents to discuss different topics?
yes
no
Would you be interested in doing "outings" as part of the social skill group to generalize these skills to the community settings as well?
yes
no
Tell me your top 3 goals that you would like to see your child accomplish through a social skills group.
Submit
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