Social Skills Program Application

Client Information

Client's Name *

First

Last

Client's Date of Birth *

Client's Gender *

Primary Diagnosis *

Does client currently receive educational, therapy (e.g., speech, PT, psychology) or other related services?

Can client use the bathroom independently?

Yes
No
Needs very minimal assistance

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Additional Client Information

Verbal language (select one)

Does not use spoken words (may communicate through gestures, sounds, AAC)
Uses a few single words (often prompted; may be unclear or inconsistent)
Uses simple phrases (e.g., want juice, go home)
May use 1 - 2 full sentences, but communication may be unclear (difficulty with back and forth or staying on topic)
Uses full sentences (engages in conversation)

Social communication (select one)

Significant difficulty with social communication (Rarely responds to other; may not understand basic social cues or conversational rules)
Limited pragmatic skills (Responds inconsistently, may use language in a way that seems off-topic, repetitive, or not directed towards others)
Emerging but inconsistent social communication (Can take turns or stay on topic with support; often needs reminders or prompting)
Functional but sometimes awkward social communication (Takes turns and responds, but may miss subtle cues, talk “at” others, or struggle with flexible conversation
Age-expected pragmatic communication (Understands social cues, participates in back and forth conversations, and adjusts language appropriately in most situations)

How interested is your child in making friends or being around peers? (select one)

Shows very little or no interest
Rarely seeks out peers
Some interest but unsure how to connect
Shows interest; may need help navigating interactions
Strong interest in friendships and social interactions

How ready is your child to participate in a small structured group with peers (listening, following directions, staying with the group) (select one)

Not ready; significant support needed
Limited readiness; requires 1:1 guidance
Some readiness; can engage with prompting
Mostly ready; follows expectations with minimal support
Fully group-ready and participates independently

following if severity

Presenting or history of challenging behavior (check all that apply)

If any of the above were checked, please describe the severity level and frequency in which it occurs and whether it is current or has occurred historically (please indicate how long ago if applicable)

What are the top social skills you would like for your child to develop in this social skills group?