SOCIAL SKILLS GROUP

5308 Derry Ave. Suite
L-201 Agoura Hills, CA 91301
Juliana@empoweringmindstogether.com
818-805-07112
SOCIAL SKILLS GROUP
PARENT INTAKE QUESTIONNAIRE
Basic Information
Child's Name:
Date of Birth:
School's Name:
Grade:
Parents Name(s):
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Has your child received any of the following? (check all that apply)

Speech TherapyOccupational TherapyABACounselingNone
Diagnosis (if applicable):
Questionnaire
How to Complete This Form
Please answer based on your child's usual behavior. There are no right or wrong answers. Choose the option that best reflects how often you see each behavior:
- Never – Rarely seen
- Sometimes – Happens occasionally
- Most of the Time – Happens often
- Always – Consistently present
- Not Applicable – This does not apply to my child
Your honest responses help us create the best fit for your child.

SECTION A - Social Interaction

Rows	Never	SometimesMost	of the Time	Always	Not Applicable
Initiates play with peers
Responds when peers initiate
Maintains conversation
Understands personal space
Takes turns appropriately
Shares materials
Reads social cues
Joins ongoing play appropriately
Has at least one friend
Feels comfortable in groups

SECTION B - Emotional Regulation

Rows	Never	Sometimes	Most Time of the	Always	Not Applicable
Handles losing appropriately
Recovers from frustration quickly
Manages transitions
Accepts changes in plans
Expresses feelings verbally
Uses coping strategies
Becomes overwhelmed in groups
Has emotional outbursts
Shuts down when frustrated
Calms independently

SECTION C — Behavior in Groups

Rows	Never	Sometimes	Most of the Time	Always	Not Applicable
Follows directions
Waits without interrupting
Interrupts others
Becomes physically impulsive
Shows flexibility in games
Argues about rules
Works cooperatively
Becomes overly competitive
Avoids participation

SECTION D - Strengths

Rows	Never	Sometimes	Most of the Time	Always	Not Applicable
Shows empathy
Strong verbal skills
Creative
Enjoys movement
Responds well to praise
Shows leadership
Motivated to improve
Enjoys structured activities

CONSENT FOR TREATMENT OF A MINOR
Child Information:
Child's Name:
Date of Birth:

MonthDayYear
Date
Parent / Legal Guardian Information:
Parent/Guardian Name:
Relationship to Child:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Parent/Guardian Name (if applicable):
Relationship to Child:
Phone:
Format: (000) 000-0000.
Consent for Treatment:
I/we, the undersigned parent(s) or legal guardian(s) of the above-named minor, give consent for my/our child to participate in Social Skills Group Therapy at Empowering Minds Together Clinic. Services are provided by Juliana Sharoni, who operates as an independent contractor under the supervision of Dr. Irit Almog.

Acknowledgment:
By signing below, I/we confirm:
- I/we have legal authority to consent for this child.
- I/we have read and understand this form.
- I/we had the opportunity to ask questions.
- I/we consent to treatment for my/our child.
Parent/Guardian Signature:
Printed Name:
Date:

MonthDayYear
Date
Second Parent/Guardian Signature (if applicable):
Printed Name:
Date:

MonthDayYear
Date
Provider Signature:
Date:

MonthDayYear
Date

Insurance / Payment Information
Please Note: Empowering Minds Together, Inc. files insurance as a courtesy to you, and you, not your insurance company are ultimately responsible for your bill. Please expect to pay your portion of copay, coinsurance, deductible, or self-pay payments at the time of service.
Self-Pay:

NoYes
Primary Insurance:
Member ID:
Secondary Insurance:
Member ID:
Referral Source (if any):
If not, how did you hear about us:
Patient Name (print):
Patient or legally authorized individual signature:
Relation to patient:
Date:

MonthDayYear
Date
Should be Empty:

CONSENT FOR TREATMENT OF A MINOR