Social Communication Groups Intake Form Patient's Name * First Name Last Name Date of Birth * MM DD YYYY Parent's Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Phone * (###) ### #### Email * Is it okay to text you? * Yes No Second Parent's Name First Name Last Name Second Parent's Address Address 1 Address 2 City State/Province Zip/Postal Code Country Second Parent's Email Second Parent's Mobile Phone (###) ### #### Is it okay to text you? Yes No Caregiver Name First Name Last Name Caregiver Mobile Phone (###) ### #### Child's School * Child's grade * Sibling's Name and Age How did you hear about us? * Pediatrician's Name Pediatrician's Phone (###) ### #### Medications * Allergies * Special Diet Diagnosis * Other professionals seeing your child? * Share your child's strengths and weaknesses * What is your goal for your child at home and school? * What brings you to the Social Mind Center? * Academic Concerns * Does your child have sensory behavioral challenges? * Active Overly Sensitive Pinches/Bites Passive Picky Eater Transition Difficulty Intense Intrudes on space Chews on non-food items Texture difficulty Sib Likes to spin/hide Bumps into things Stims Fear in a space (or slide) Rigid Likes rough housing Upset with change Tell us about your child's attention/focus: * Distracted Intensely focused Impulsive Forgetful Disorganized Makes careless mistakes Fidgets Talks excessively Difficulty waiting Loses things Lacks awareness Preoccupation Does your child have social learning challenges? * Verbal turn taking Reading cues Maintaining topic Recognize emotions Eye contact Proximity Perspective Initiation Concrete Thinking Friendship Difficulty Inferencing Self-awareness Reading Comprehension Joint attention Limited topics Listening Has your child ever participated in a group? * Yes No Does your child participate in extracurricular activities? Please list if any. * Programs of Interest * Social Communication Group Messy Art Creative Social Group Movement Creative Social Group Science Collaborative Social Group Counseling Speech & Language Therapy Occupational Therapy Psycho-Educational Assessments Thank you for submitting!
