Social Group Caregiver Questionnaire
Step
1
of
4
25%
Child's Name
(Required)
First
Last
Parent/Caregivers Name(s)
(Required)
Add
Remove
Name of School
(Required)
Name of Person Completing Form
(Required)
First
Last
Relationship to Child
(Required)
1. How did you hear about us?
2. Services that your child has received or currently receives
Occupational Therapy
Speech Therapy
ABA
Physical Therapy
Mental Health Counseling
Select All
3. Please list any social activities of extracurricular activities that your child is currently involved in
4. Does your child participate in play dates with peers his/her age outside of the school environment?
Yes
No
5. What is motivating to your child (ex. super heroes, TV shows, games)?
6. What are your child’s strengths?
7. What would you like to see your child improve upon while participating in “Fun Fitness-Social Skills” Group? (ex. increased confidence, improved peer interaction, initiating play with peers)
Please indicate your child’s social behavior in the following areas:
Sensory Processing/Regulation
Initiates social interactions/play with appropriate peers
(Required)
Never
Rarely
Sometimes
Often
N/A
Has good self-confidence in social situations
(Required)
Never
Rarely
Sometimes
Often
N/A
Appears to be more nervous or “fidgety” in social situations
(Required)
Never
Rarely
Sometimes
Often
N/A
Prefers to play and communicate with adults or older peers
(Required)
Never
Rarely
Sometimes
Often
N/A
Enjoys playing with a wide variety of toys/games
(Required)
Never
Rarely
Sometimes
Often
N/A
Appears confident when interacting/playing with age appropriate peers
(Required)
Never
Rarely
Sometimes
Often
N/A
Appears to understand emotions of others (peers and adults)
(Required)
Never
Rarely
Sometimes
Often
N/A
Responds appropriately when he/she does not win a game
(Required)
Never
Rarely
Sometimes
Often
N/A
Understands and appropriately uses “turn taking” skills while playing games
(Required)
Never
Rarely
Sometimes
Often
N/A
Please indicate your child’s social behavior in the following areas:
Social/Play Skills/Emotions
Has difficulty with changes in routine
(Required)
Never
Rarely
Sometimes
Often
N/A
Has difficulty remaining seated during circle time or tabletop activities
(Required)
Never
Rarely
Sometimes
Often
N/A
Becomes easily frustrated
(Required)
Never
Rarely
Sometimes
Often
N/A
Avoids being touched and getting “messy”
(Required)
Never
Rarely
Sometimes
Often
N/A
Has difficulty in large groups or crowds
(Required)
Never
Rarely
Sometimes
Often
N/A
Has difficulty understanding personal space and boundaries (gets too close to peers, touches people/objects frequently)
(Required)
Never
Rarely
Sometimes
Often
N/A
Frequently bumps into things and falls/appears “clumsy”
(Required)
Never
Rarely
Sometimes
Often
N/A
Avoids difficult equipment on the playground/tends to gravitate towards the same play equipment
(Required)
Never
Rarely
Sometimes
Often
N/A
He/She has narrow food preferences and has difficulty trying new foods
(Required)
Never
Rarely
Sometimes
Often
N/A
Please indicate your child’s social behavior in the following areas:
Communication/Language
Enjoys talking about a wide variety of topics
(Required)
Never
Rarely
Sometimes
Often
N/A
Understands and uses appropriate tone and volume (i.e. “inside voice” vs “Playground voice”)
(Required)
Never
Rarely
Sometimes
Often
N/A
Makes appropriate eye contact when communicating with peers and adults
(Required)
Never
Rarely
Sometimes
Often
N/A
Verbally communicates his/her emotions
(Required)
Never
Rarely
Sometimes
Often
N/A
Following school, he/she can accurately describe parts of their day
(Required)
Never
Rarely
Sometimes
Often
N/A
Can utilizing basic turn taking during a conversation with peer or adult
(Required)
Never
Rarely
Sometimes
Often
N/A
Understands and responds to facial expressions and tone of others
(Required)
Never
Rarely
Sometimes
Often
N/A
Please provide any further information/goals/concerns that would assist us in maximizing your child’s experience
