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:
School Details:
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
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:
Further Information required:
Due to the extensive preparation that is involved with the group, a deposit of $100 is required to secure a place for your child. The deposit should be paid ASAP as a place cannot be held without it.
Please pay via cash, cheque (made out to: Lauren Reinhardt) or Credit Card. The deposit will count towards the total fee of $490, therefore only $390 need be paid at the commencement of the 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:
January School Holidays Social Skills for the School Starter - January 18th to 22nd 2010 (Chatswood) January School Holidays Basic Social Skills Group - January 18th to 22nd 2010 (Chatswood) January School Holidays Advanced Social Skills Group - January 18th to 22nd 2010 (Chatswood) April School Holidays Junior Social Skills Group - April 12th to 16th 2010 (Hornsby) April School Holidays Basic Social Skills Group - April 12th to 16th 2010 (Hornsby) April School Holidays Advanced Social Skills Group - April 12th to 16th 2010 (Hornsby) July School Holidays Junior Social Skills Group - July 5th to 9th 2010 (Hornsby) July School Holidays Basic Social Skills Group - July 5th to 9th 2010 (Hornsby) July School Holidays Advanced Social Skills Group - July 5th to 9th 2010 (Hornsby) October School Holidays Junior Social Skills Group - September 27th to October 1st (Chatswood) October School Holidays Basic Social Skills Group - September 27th to October 1st (Chatswood) October School Holidays Advanced Social Skills Group - September 27th to October 1st (Chatswood)
Thank you for taking the time to fill out the enrollment form and we will contact you shortly.
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