Intake Form | Collective Behavioral Therapy

Social Skills Group

In this five week program individuals with autism can learn and practice social skills with peers who may be struggling with similar issues. Through a combination of evidence-based strategies, including role-playing, peer modeling, and social stories, we aim to build not just competence but confidence in social situations. For more information you can reference "Our Services" page.

Child's Name and Information

First and Last name

Date of Birth

Phone Number

Parent's Name

Address

City

State

Zip Code

Child's Language

English

Spanish

Other

Preferred Contact Method

Phone Call

Text

Best Time To Contact

Morning

Afternoon

Evening

Describe your child's communication:

Non-Vocal but uses Communication Device or other forms of communication

Vocalizes wants and needs clearly (more than 1 word requests)

Engages in complex speech

Emerging learner: some words, but difficult to understand

How did you hear about us?

Has your child been diagnosed with Autism Spectrum Disorder?

Yes

Referred for an Autism Evaluation

My child doesn't have an autism diagnosis

My child has a diagnosis other than Autism

Is your child able to express their wants, needs and preferences?

Yes

Sometimes

Is your child able to identify the emotions that they are feeling?

Yes

Sometimes

Does your child identify emotions in others?

Yes

Sometimes

Does your child follow multi-step directions?

Yes

Sometimes

Is your child agressive towards peers?

Yes

Sometimes

Is your child agressive towards self?

Yes

Sometimes

Does your child prefer to play on their own?

Yes

Sometimes

Does your child understand humor?

Yes

Sometimes

Does your child follow rules during games?

Yes

Sometimes

Is your child accepting of comfort from others when upset?

Yes

Sometimes

Is your child able to calm himself/herself down when upset?

Yes

Sometimes

Does your child accept losing a game without becoming overly upset?

Yes

Sometimes

Does your child have a sense of pride in his/her achievements?

Yes

Sometimes

Does your child accept making mistakes without becoming overly upset or angry?

Yes

Sometimes

Does your child engage in activities for more than a few minutes? (iPad games, playing with blocks, listening to music, etc.)

Yes

Sometimes

Is there anything else you would like us to know about your child?