SOCIAL SUCCESS! PARENTS PLEASE HAVE YOUR CHILD’S EDUCATOR/THERAPIST FILL THIS OUT Dear Professional, Date: ___________ Name of Student: ________________________________________________________ is being considered for placement in a group at our practice. It would be greatly appreciated if you could complete the below information regarding this student based on your own experience. Your Name: ___________________________________ of Student: _______________________ Relationship to the student: _____________________________________________________________ Please check off where you feel how this person does in your setting in the following areas: AT BELOW NOT SKILL COMMENTS GRADE GRADE GRADE OBSERVED LEVEL LEVEL LEVEL Math Reading Decoding Reading Comprehension Written Expression Participating as part of the large group during class discussion/lecture Participating as part of a small group in class Making and keeping friends during free time Ability to ask for help in class Organizational skills in class Organizational skills from home to school and back Does this child stand out as If Yes, please explain? unique in his interpersonal skills, either in class or out of class? Do you anticipate that this If Yes, please explain? student will encounter more challenges in future school years? How would this student’s peers describe him/her?
SOCIAL SUCCESS! PARENTS PLEASE HAVE YOUR CHILD’S EDUCATOR/THERAPIST FILL THIS OUT Dear Professional, Date: ___________ Name of Student: ________________________________________________________ is being considered for placement in a group at our practice. It would be greatly appreciated if you could complete the below information regarding this student based on your own experience. Your Name: ___________________________________ of Student: _______________________ Relationship to the student: _____________________________________________________________ Please check off where you feel how this person does in your setting in the following areas: SKILL COMMENTS GRADE LEVEL AT GRADE LEVEL BELOW GRADE LEVEL NOT OBSERVED Math Reading Decoding Reading Comprehension Written Expression Participating as part of the large group during class discussion/lecture Participating as part of a small group in class Making and keeping friends during free time Ability to ask for help in class Organizational skills in class Organizational skills from home to school and back Does this child stand out as unique in his interpersonal skills, either in class or out of class? If Yes, please explain? Do you anticipate that this student will encounter more challenges in future school years? If Yes, please explain? How would this student’s peers describe him/her?
complete%20Intake%20Form%20Form%202017%20Ages%20%208-18.docx