Interest Form for Social Skills Group
Please complete this interest form for each child for one of our After-School Social Groups. For questions, please contact us at 205-957-0298 or info@mitchells-place.com. Completion of this form does not guarantee enrollment in the group.
Name
*
First Name
Last Name
Child's grade in 2021-2022 school year?
*
Child's birth date
*
-
Month
-
Day
Year
Date
Child's legal guardian(s):
*
Both birth parents
Birth mother
Birth father
Adoptive parents
Department of Human Resources
Other
Guardian's Name:
*
First Name
Last Name
Second Guardian's Name (please type N/A if single parent):
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Primary Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Phone Number:
Please enter a valid phone number.
Secondary Email:
example@example.com
Referred by:
First Name
Last Name
What school does your child currently attend?
*
Does your child currently receive school services?
*
Yes
No
Does your child have an IEP or 504?
*
Yes
No
Child's Diagnosis:
*
Autism
Asperger's
PDD- NOS
ADHD
ADD
Other
Who made the diagnosis (name of doctor):
*
When was the diagnosis made?
*
-
Month
-
Day
Year
Date
Is your child on any special diet?
*
Yes
No
If yes, please describe:
Does your child take any medications?
*
Yes
No
Does your child have any allergies?
*
Yes
No
If yes, please list:
Does your child have “outbursts” or “meltdowns” due to anger, frustrations, and/or sensory overload? (If yes, please describe what the behavior looks like.)
*
Is your child typically compliant with adult demands? (If no, what are some strategies you have used that gain compliance?)
*
Siblings (please include name, age and any learning/medical conditions):
*
Describe the concerns you have that prompted your referral (for example: behavioral problems, problem solving skills, personal/social skills, speech or language development).
*
Describe your child’s play/social skills:
*
What are your child’s special interests?
*
Submit
Should be Empty: