Expressive Arts Group Member Questionnaire
Parent/Guardian Information
Parent/Guardian Name(s):
*
First Name
Last Name
Phone Number:
*
Email Address:
*
example@example.com
Preferred Contact Method (Circle):
*
Phone
Email
Parent/Guardian Name(s):
First Name
Last Name
Phone Number:
Email Address:
example@example.com
Preferred Contact Method (Circle):
Phone
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Information
Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender:
*
Current Grade:
School:
Does your child have an IEP or 504 Plan? (Circle):
*
Yes
No
If your child has an IEP/504 Plan, please briefly describe accommodations or services:
*
Family & Household Information
Who lives in the household with your child?
Primary language(s) spoken at home:
*
Are there any significant family changes or stressors we should be aware of (e.g., divorce, relocation, illness, loss)?
*
Developmental & Medical History
Has your child received any previous diagnoses? If yes, please describe (e.g., ADHD, Autism Spectrum Disorder, anxiety, depression, learning disability):
*
Is your child currently receiving any therapeutic services? (e.g., counseling, occupational therapy, speech therapy, tutoring) If yes, please describe:
*
Is your child currently taking any medications? If yes, please list medication name(s) and purpose:
*
Are there any medical conditions, allergies, or physical health concerns we should know about? If yes, please describe:
*
Social & Emotional Functioning
Social Challenges: What social or emotional difficulties does your child experience? (Check all that apply)
*
Difficulty reading social cues or body language
Trouble starting or maintaining conversations
Difficulty managing frustration or anger
Anxiety in social situations
Low self-esteem or self-confidence
Impulsivity or difficulty with self-control
Trouble cooperating or working in groups
Difficulty understanding others' perspectives
Other
Emotional Regulation: How does your child typically handle big emotions (anger, sadness, frustration, excitement)?
*
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Expressive Arts Group Member Questionnaire
Behavioral Concerns
Are there any behavioral challenges at home or school (e.g., defiance, aggression, withdrawal, avoidance)? If yes, please describe:
*
How does your child respond to feedback, redirection, or correction?
*
School Functioning
Are there any specific challenges at school (academic, behavioral, social)?
*
Goals & Expectations
Previous Group or Therapeutic Experience: Has your child participated in social skills groups or therapy groups before? If yes, what worked well? What didn't work?
*
Additional Information
What kinds of artistic or creative activities does your child enjoy or have they participated in previously? Please provide examples.
*
Does your child have any sensory sensitivities to sound, touch, textures? There will likely be a musical component to the group for at least one of the sessions.
*
Is there anything else we should know about your child that would help us support them effectively?
Consent & Next Steps
By submitting this questionnaire, I understand that Triumph Center staff will review this information to determine my child's appropriateness for this group. I consent to being contacted to discuss next steps.
Parent/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
Date
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