Achieve Therapy Services Social Skills Group and Social / Play Group Application

Date:

Child's name:

Date of Birth:

Child's Age:

Address: City:

Zip code:

Home phone:

Email:

Father's name:

Mother's name:

Mom work phone:

Mom cell:

Dad work phone:

Dad cell:

Alternate contact name and #:

Alternate contact's number:

Child lives with: Mother Father Both Parents Other

Please list your child's allergies:



Does your child have a diagnosis related to any of the following:

Speech and language ADD Anxiety Autism ADHD

• Please list medication your child is currently taking



• Where does your child attend school?



• What grade is your child in?



• Can your child read?
Yes No


• Does your child receive speech and language services?

Yes No


• How many times per week does your child receive speech and language services?






What is the focus of speech and language therapy?






• Does your child recieve occupational therapy?





• What is the focus of occupational therapy?





• Does your child receive counseling services?


Yes No


• If so, where?





• Does your child demonstrate behavior difficulties that may require additional attention during a group activity? If so, please list examples of these behavior difficulties.





• What do you or your child's therapists, teachers, or counselors do to address and deal with inappropriate or disruptive behaviors your child exhibits?
  
  
  
  Does your child have difficulty making or keeping friends?
  
  Yes No
  
  
• Does your child have difficulty interacting with others?


Yes No


• Does your child interact differently with peers versus adults


Yes No


• If so, what is the difference?





• I , give Achive Therapy Services permission to release and obtain information about my child to the following people or facilities: ( Please list any professionals and their contact information that you would like us to be able to communicate with about your child )
  
  
  
  
• Please check any skills that your child needs to learn or practice:
  
  Eye Contact Boundaries Personal Space Sharing
  Playing with others Joining an ongoing activity
  Identifying and regulating energy levels
  Using appropriate language to interact in a social situation
  Conversations Topic Maintenance Interrupting
  Turn taking Initiating play Identifying emotions
  
  
• Please also write a brief description of your child and his/her difficulties with speech, language, anxiety, and social interactions




Please contact Mary Martha Melancon with any questions concerning the groups at 704.708.8314 or by email at spidge@windstream.net. More information can also be obtained at our website: www.achivetherapyclinic.com.