Social Skills Groups 2012 Enrolment Form | Northshore Speech Therapy

Enrolment Form

Dear Parents,

Thank you for your interest in the Social Skills Groups at Northshore Speech Therapy. The groups are always rewarding and enjoyable for those involved. In order to ensure maximum benefit for your child, please complete this questionnaire providing as much detail as possible.

* Denotes a required field.

Personal Details:

Child's Name:	*	Date of Birth:	*
Parent's Name/s:	*	Home Phone Number:	*
Address:	*	Work Phone Number:
Email Address:	*	Mobile Number:

School Details:

School Name:	*	School Phone Number:
School Address:	*	School Year & Teacher:

Health Cover Details:

Health Insurance:
You should be able to claim back a significant amount from your private health fund.

Other Therapist's Information:

	Profession	Name
Other therapists involved with you child's care:

Further Child' Information:

Who suggested that your child attend the Social Skills Group?

Please describe your child's difficulties:

Does your child have any behaviours that might inhibit his/her progress in the group? (If Yes, please describe the behaviours and note any successful strategies that you currently use.)

If your child has been seen by other professionals (i.e. Speech Pathologists/Paediatricians/Psychologists) in the past please elaborate on any findings, diagnoses and treatment.

Does your child have any particular dietary requirements (eg, no lollies or no preservatives etc.)

Please list some of your child's interests

Please list some of your child's strengths (at school or at home).

Child' Interaction Difficulty Levels:

1) Greeting familiar people
No Difficulty	Some Difficulty	Lots of Difficulty
2) Starting a conversation
No Difficulty	Some Difficulty	Lots of Difficulty
3) Taking turns in games/activities and sharing
No Difficulty	Some Difficulty	Lots of Difficulty
4) Taking turns in conversation
No Difficulty	Some Difficulty	Lots of Difficulty
5) Staying on the topic of conversation, i.e., not going off on tangents
No Difficulty	Some Difficulty	Lots of Difficulty
6) Changing the topic of conversation appropriately, i.e., not too abruptly or not interrupting
No Difficulty	Some Difficulty	Lots of Difficulty
7) Making and Keeping friends
No Difficulty	Some Difficulty	Lots of Difficulty
8) Making eye-contact when speaking with someone
No Difficulty	Some Difficulty	Lots of Difficulty
9) Solving Problems
No Difficulty	Some Difficulty	Lots of Difficulty
10) Working in a group
No Difficulty	Some Difficulty	Lots of Difficulty
11) Avoiding arguments with peers of own age
No Difficulty	Some Difficulty	Lots of Difficulty
12) Recognising and managing emotions in self
No Difficulty	Some Difficulty	Lots of Difficulty
13) Recognising and responding to emotions in others
No Difficulty	Some Difficulty	Lots of Difficulty

Further Comments:

If you have any other information about your child, comments about what you wish for your child to achieve from the group, or suggestions, please write them here:

How did you find out about the groups?

Thankyou for taking the time to fill in this questionnaire, it will most certainly help with ensuring that you child gains as much as possible from the group.

To assist us with future advertising please check the boxes that apply:

	School Newsletter (school)
	School Teacher (school)
	School Principal (school)
	School Counsellor (school)
	Saw flyer displayed (where)
	Friend (who)
	Other (details please)

Further Information required:

•	Once you have submitted your child’s enrolment, our office will contact you to take payment for the group. We usually fill the groups quickly and some students miss out. Payment is required to secure your child’s place in the group. If you do wish to withdraw your child’s enrolment your payment will be refunded if we can offer your child’s place to someone else. If not then your payment will be credit towards the next group.

•	If you have recent reports from your child's school, therapists, paediatrician etc., it is recommended that you send a copy of these with the questionnaire. The reports prove useful in preparing for your child's needs.

•	We will be compiling an "All About Me" board for children to learn about each other. A standard sized photograph (15cm X 10cm) is required for this board.

Note: You will be contacted shortly to complete the deposit payment and to arrange the submission of reports and photograph, upon sending this enrollment form.

Please select the group that you are interested in:

Thank you for taking the time to fill out the enrollment form and we will contact you shortly.