Regulating Together Interest Intake Form

Caregiver (your) name*

First NameLast Name

Email*

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Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

City*

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Your child's first name*

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School District of Residence*

School of Attendance*

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Yes - documentation will be requested laterNoIn progressNot sure

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Emotional dysregulation means your child has trouble managing strong feelings. They may become upset very quickly (“go from 0 to 60”), react too strongly to the situation, or stay upset for a long time. It may also be hard for them to calm down once they are upset.

This is different from social skill challenges, which involve things like joining in, talking with others, or understanding social cues. A child with social skill difficulties may struggle in groups but can usually stay calm when things don’t go their way. Emotional dysregulation means the main challenge is controlling emotions and reactions, not just social understanding.

YesNoUnsure

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Regulating Together Interest Form

Emotional Regulation