School Based Intervention Screener

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)
Remain calm when experiencing undesired outcomes (no physical aggression and/or vocal outbursts)(Required)
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)
Ability to verbally communicate wants & needs to peer(s) and group facilitators in appropriate manner(Required)
Ability to answer questions with minimum of 4–5 word sentence response(Required)

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.
How did you hear about our program?(Required)

Contact Information

MM slash DD slash YYYY
Classroom Category(Required)


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.