School Based Intervention Screener

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School Based Screener

PREREQUISITE FOR PROGRAM ADMISSION: Child MUST have the following foundational skills for the group intervention to be impactful.

Please select yes or no to the questions below:

Follow group rules in a classroom setting (minimum of 4-step instruction)(Required)

Yes

No

Remain calm when experiencing undesired outcomes (no physical aggression and/or vocal outbursts)(Required)

Yes

No

Must be able to remain seated & compliant at a table in a group therapy class setting for a minimum duration of 15-20 mins at a time(Required)

Yes

No

Ability to verbally communicate wants & needs to peer(s) and group facilitators in appropriate manner(Required)

Yes

No

Ability to answer questions with minimum of 4–5 word sentence response(Required)

Yes

No

Does your child/student need additional support to do the following things below:

Developing/maintaining friendships, interpreting body language and social cues of others, managing and self-regulating emotions of others, developing self-advocacy skills, and developing self-confidence.

Which area(s) of your student’s social skills growth are you most concerned about? (25-word limit)(Required)

How did you hear about our program?(Required)

If other, please identify how you heard about the program.

Contact Information

Name(Required)

First Last

Job Title(Required)

Date(Required)

Phone(Required)

Email(Required)

Enter Email Confirm Email

School(Required)

Student Age Range(Required)

Classroom Category(Required)

If other was selected please provide more details below:

Disclaimer

PLEASE NOTE: This is not a guarantee of services. This form is utilized as an initial screening process for staff purposes only. If it is determined that your classroom may be a potential fit for this program, you will be contacted by a member of our staff to schedule a classroom observation.