Social Smarts

Client Information Returning Client?
Child's Name:
Date of Birth:
School:
Age: Years months
Gender:
Grade (in September):

Parent Information
Parent #1
Name:
Address:
City: Province:
Postal Code:
Home Phone #:
Cell Phone #:
Work Phone #:
E-mail:
Permitted to pick up my child
Best Method to Contact:
Parent #2
Name:
Address:
City: Province:
Postal Code:
Home Phone #:
Cell Phone #:
Work Phone #:
E-mail:
Permitted to pick up my child
Best Method to Contact:

Emergency Contact Information
Name:
Phone #:
Relationship to Child:
Alternate Phone #:

I would like to register my child for:
Social Smarts Summer Day Camp: August Social Smarts Weekly Group Sessions:
Fall/Winter
- Tuesday or Wednesday afternoon/evenings

Health Information
Please list any food allergies or diet restrictions for your child: Needs Epi-Pen?
Please list any medical conditions, physical limitations, or other concerns which might affect your child's participation in the program.

Photographic and Media Consent
With your consent, we would like the opportunity to take pictures and/or videos of your child during therapy or group sessions for the purposes of training Social Smarts employees and educating parents and other professionals about our therapeutic program. These recordings of the interactions that take place during therapy help us to illustrate the therapeutic techniques and social strategies that we use in the Social Smarts program.

I give permission for photographs and/or videos of my child to be used for educational purposes in both clinical and conference settings.

PARENT QUESTIONNAIRE
The following questionnaire will help us understand your child's strengths and weaknesses. Thank you for taking the time to provide us with this valuable information. Please check all that apply to your child.

Communication:
Expressive Language Development (vocabulary and sentence structure)
Advanced Age-expected Slightly delayed Significantly delayed*

*Note: Social Smarts is a language-based program, so it is best suited for children who have already acquired solid language skills.

Characteristics:
Unmotivated
Unfocused
Anxious
Active and distracted
Impulsive
Rigid
Inattentive or aloof ("in his/her own world")
 Oppositional
Physically aggressive towards peers
Verbally aggressive towards peers
Physically aggressive towards adults when upset
Verbally aggressive towards adults
May run away or want to leave situation when upset
Other:

Play and Interaction Style:
Appears unaware of others unless he/she needs something
Plays near peers
Notices and imitates others in play (does what peers are doing)
Plays with others in a structured or familiar activity
Prefers to play with adults
Is interested in others but struggles with sustaining play beyond his/her own toys, themes, or topics of interest (e.g. always wants to play trains, talk about dinosaurs, etc.) 		Plays with peers with adult help to:
  - Initiate play/get play started
  - Sustain play/keep play going
  - Solve problems that come up during play
Allows others to add ideas to play
Difficulty being flexible around another's wants or interests
Preference for individual play/activities

Toys, Games, and Pretend Play:
Moves from toy to toy without really playing
Focuses on physical aspects of toys (e.g., spins wheels on cars, lines toys up)
Play is self centered and structured (e.g., putting the pieces in a puzzle, driving a train along a track)
Plays circle games, music, or physical activities with peers
Plays simple turn-taking games with a peer with adult help
Can play along a familiar theme with some variation introduced (e.g., train can take cows to the park)
 Pretends with realistic objects (e.g., drinks from an empty cup, answers a toy phone, makes a toy cow eat grass)
Can pretend play familiar experiences with toys that look like what they are (e.g,. pushing a shopping cart)
Plays pretend using imagination and objects and can substitute one object for another (e.g., will use a banana as a phone or a stick as a horse)
Plays pretend without objects, talking about ideas and imagination
Plays pretend with adults
Plays pretend with peers

Please answer the following questions to give us more detailed information about your child. Provide examples where possible.

What are your main concerns about your child's social functioning?

What are your child's social strengths and weaknesses?

How would you describe your child's typical interactions with peers?

Is your child aware of his/her social challenges? (e.g., Is he/she aware of how others perceive him/her? Does he/she think that he/she is perceived as "different" from peers?)

To what extent does your child understand that his/her actions and words affect others?

How does your child respond to everyday problems, such as changes in routine, conflicts with peers, etc.?

Is your child able to follow one-step, two-step, and/or three-step instructions? (For example, a two-step instruction might be, "Hang your coat up in the closet, and then bring your backpack into the kitchen.")

Does your child need gestures (pointing) or other support (multiple repetitions, pictures, physical prompts, etc.) to understand your directions?

Is it hard to get your child's attention?

Can you have a conversation with your child?

If I were to observe your child on the playground, what would I notice about him/her?

If I were to observe your child in the classroom, what would I notice about him/her?

If I were to observe your child on a play date with a peer, what would I notice about him/her?

If I were to observe your child playing at home, what would I notice about him/her?

What is your child's preferred toy or activity?

What percentage of time do they play with this toy/engage in this activity, as compared to other activities?


©2012 Copyright - Dr Pam Struiksma - All rights reserved. - Designed by Net Zone Media -