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Child's Full Name:*
Date of Birth:*
Gender:*
Any medical conditions we should be aware of while your child is under our care? Check all that apply: food allergiesseasonal allergiespet allergieseczemaasthmafrequent coldshearing impairmentvision impairmentdigestive concernsseizure disorderdiabetesanemiahyperglycemiaOther
Please specify whether your child has any food allergies.* YesNo
Does your child carry an Epipen? YesNo
Name of current school and grade in 2023-24:*
Days and hours of attendance at current school:*
Language(s) spoken and understood at home:*
Please share any specific diagnoses given:*
Parent/Guardian First Name and Last Name:*
Relationship to Child:*
Contact Information
Phone:*
Email:*
Emergency Contact Name and Number in case we cannot reach parent:
Contact Name:*
Complete Home Address:*
Which social group(s) are you interested in registering for?
SelectMommy/Daddy and me Mondays 10:00 in San JosePreschool & TK Mondays 11:00 in San Jose4-5 year-olds Mondays 4:15 in Mountain View6-8 year-olds Mondays 5:30 in Mountain ViewElementary Thursdays 3:15 in San Jose (exact ages TBD)School age Fridays 3:15 in San Jose (exact ages TBD)Kinder to Lower Elementary Saturdays 8:30am in San JoseUpper Elementary through Middle School Saturdays 9:30am in San JoseSelectMommy/Daddy and me Mondays 10:00 in San JosePreschool & TK Mondays 11:00 in San Jose4-5 year-olds Mondays 4:15 in Mountain View6-8 year-olds Mondays 5:30 in Mountain ViewElementary Thursdays 3:15 in San Jose (exact ages TBD)School age Fridays 3:15 in San Jose (exact ages TBD)Kinder to Lower Elementary Saturdays 8:30am in San JoseUpper Elementary through Middle School Saturdays 9:30am in San Jose
What is your reason for joining this social group?*
Has your child attended a social group before? If so, which one(s)?* YesNo
Which one(s)?
Has your child had individual speech therapy before? If so, please elaborate.* YesNo
What are your child’s specific interests or hobbies that they might want to share with the group?*
Is there anything specific you would like your child to gain from this social group?
Help us learn more about your child. We have designed the following questions so we can best prepare for our groups and anticipate the children’s needs.
Please describe your child’s attention span. My child typically attends to a structured, adult-led activity for:* 0-2 minutes3-5 minutes6-10 minutes10-15 minutes>15 minutes
Please describe your child’s overall energy level. Check all that apply.* My child likes to move around a lotMy child likes to climb on furnitureMy child tends to remain seated in one placeMy child often slumps in the chairMy child needs encouragement to stay engaged in activities
Please describe your child’s personality. Check all that apply.* My child is very talkative but only with people he/she knowsMy child is extraverted and likes to talk to anyone aroundMy child is very shy most of the timeMy child tends to be reserved in new situations, but later becomes outgoingMy child is slow to build trust with unfamiliar peopleMy child shows a lot of interest in same-age peers and actively tries to engage with them (whether successfully or not)My child shows some degree of interest in same-age peers but only sometimes or rarely attempts to engage with themMy child does not show interest in peersOther
We would like to learn about your child’s response to environmental stimuli, transitions and changes in routine. Please check all that apply.* My child is easily affected or dysregulated as a result of sensory processing differences.My child finds transitions between activities challenging.My child may become upset if things don’t go as planned or discussedMy child is very attached and becomes anxious when we have to separateMy child has tried to escape a classroom / therapy room / extracurricular activity / other locationI have more to say about thisNone of these apply
Feel free to share any other relevant information:
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