Social Group Caregiver Questionnaire Social Group Caregiver Questionnaire Step 1 of 4 25% Child's Name(Required) First Last Parent/Caregivers Name(s)(Required) Add RemoveName 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 All3. 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/RegulationInitiates 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/EmotionsHas 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/LanguageEnjoys 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
