Social Skills Group - Intake Form

For help in filling out this form, please contact or call 617-505-6183.

Parent/Caregiver information
Person completing form *
Person completing form
e.g. parent, teacher, etc.
Student information
Student's Name *
Student's Name
Please list any food or medication allergies.
Please list all medication taken as well as any other relevant medical history (seizure disorders, visual impairments, etc.)
Date of birth *
Date of birth
Modes of communication
Please select any/all modes of communication reliably used by your child.
Please list goals for your child. This might include skills to work on or behaviors to decrease.
Please list any challenging behaviors that your child engages in.
Please list any items or activities your child is interested in or enjoys engaging in.
Please tell us about a recent peer interaction (e.g., describe how he/she behaved at the last birthday party you brought him/her to).
Social Skills Groups are scheduled to run for 10-11 weeks. Please note that families who have existing weekday services may be able to transition those session times to a social skills group.
Please list the times your child would be available on each day of the week, including weekends (example: Monday 3-7p, Tuesday not available, Wednesday 4-6p, etc.). Social Skills will now be offered on Saturdays, dependent on enrollment.
Please select how the services will be funded.
Please let us know about any scheduling questions or concerns you may have related to the available session times.