Social Group Interest Form
Bloom uses this information to learn about your child and determine whether we may be able to create or offer a group with peers who have compatible ages, communication skills, social goals, support needs, and schedules. Submitting this interest form does not guarantee placement. We will contact you if an appropriate group opportunity becomes available.
Child Information
Child Information
Child's name
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First Name
Last Name
Child's date of birth
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Month
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Day
Year
Child's age
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Child's school
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Type N/A if not applicable.
Has your child attended Bloom before?
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Yes
No
Group Matching Information
Group Matching Information
Which social skills are currently most challenging for your child? Please describe any difficulties with joining peers, back-and-forth conversation, turn-taking, flexibility, reading social cues, or managing disagreements.
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What would you like your child to gain from participating in a social skills group?
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Please describe your child’s spoken language skills, including how they express wants, needs, and ideas, understand others, and participate in back-and-forth conversation. Please also describe their ability to focus and sustain attention during activities.
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Please describe any current or previous evaluations, diagnoses, and services, such as OT, PT, speech therapy, behavioral support, counseling, or school-based services.
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Please describe your child’s strengths, interests, preferred activities, and motivators.
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Please describe any sensory sensitivities, sensory-seeking behaviors, triggers, or regulation strategies that help your child participate successfully.
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How does your child typically participate in a structured small group? Please describe their ability to remain with the group, follow adult directions, transition between activities, and participate without frequently disrupting others.
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Are there any safety concerns we should know about, including elopement, aggression, self-injury, seizures, choking risk, or difficulty following safety directions?
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Please list any current medications, medical conditions, or accommodations and supports that may affect group participation.
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Child’s Availability for a Group
Child’s Availability for a Group
Which days could your child consistently attend a weekly social skills group? Select all that apply.
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Schedule is flexible or varies
For each day selected, please list all times your child could attend. Include the earliest arrival time and latest end time, as well as school dismissal time if relevant.
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Would your child generally be able to attend the group consistently for the full program session?
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Yes
No
Not sure — please contact me
Parent / Caregiver Information
Parent / Caregiver Information
Parent / Caregiver name
*
First Name
Last Name
Parent / Caregiver email
*
Parent / Caregiver primary phone
*
Format: (000) 000-0000.
Parent / Caregiver other phone
Format: (000) 000-0000.
Please list the best days, times, and method(s) to reach you.
*
Parent / Caregiver #2 name (optional)
First Name
Last Name
Parent / Caregiver #2 email (optional)
Parent / Caregiver #2 primary phone (optional)
Format: (000) 000-0000.
Today's Date
*
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Month
-
Day
Year
Date
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