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.
Health Cover Details:
Other Therapist's Information:
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
2) Starting a conversation
3) Taking turns in games/activities and sharing
4) Taking turns in conversation
5) Staying on the topic of conversation, i.e., not going off on tangents
6) Changing the topic of conversation appropriately, i.e., not too abruptly or not interrupting
7) Making and Keeping friends
8) Making eye-contact when speaking with someone
9) Solving Problems
11) Avoiding arguments with peers of own age
12) Recognising and managing emotions in self
13) Recognising and responding to emotions in others
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:
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.
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:
April 2013 School Holidays Basic Social Skills Group - April 15th to 19th
April 2013 School Holidays Junior Social Skills Group - April 15th to 19th
July 2013 School Holidays Social Skills Group - July 8th to 12th
October 2013 School Holidays Social Skills Group - October 1st to 4th
Thank you for taking the time to fill out the enrollment form and we will contact you shortly.
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