Apply Online for ADHD Social Skills Training The text you enter here is displayed directly below the form name. This could be, for example, a description, some instructions, or any other information. Child/Adolescent Information First NameLast NameGenderAgeDate of BirthFormat: XX-XX-XXXXGradeDiagnosisMedicationsMedical Concerns we should know about (e.g., food allergies) Family Information Caregiver Name 1Cell Phone NumberFormat: XXX-XXX-XXXX Home Phone NumberFormat: XXX-XXX-XXXX Work Phone NumberFormat: XXX-XXX-XXXX Relationship to ChildCaregiver Name 2Cell Phone NumberFormat: XXX-XXX-XXXX Home Phone NumberFormat: XXX-XXX-XXXX Work Phone NumberFormat: XXX-XXX-XXXX Relationship to ChildPrimary e-mailStreet AddressCityState Outside of USA Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Idaho Iowa Illinois Indiana Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip CodeFormat: XXXXXHow did you hear about us? Have you worked with us before? Former Social Skills Summer Treatment Program Individual Parent Coaching Other Social Skills of Concern Check all that apply and rate the severity using the scale provided Normal; Not at All Borderline Problem Mild Problem Moderate Problem Marked Problem Severe Problem Most Extreme Problem Making/Keeping FriendsListening During ConversationInterrupting AppropriatelyAccepting LimitsFollowing Instructions/RulesResponding To TeasingParticipating In A GroupAsking/Answering QuestionsInitiating ConversationMaintaining Eye ContactSolving Problems/NegotiatingGiving/Accepting Negative FeedbackGiving/Receiving ComplimentsGiving/Receiving HelpInitiating Cooperative VenturesAggressive BehaviorOther Goals and Development What are your goals for your child’s participation? For example, you may want your child to develop certain skills. If so, name the skills. You may wish for your relationship with your child to be different. If so, in what ways? Describe the best things about your child. Does your child have difficulty with aggression (e.g., hit others, bite)? Please explain. Does your child have a current/past therapist? Who? What was the experience like? CAPTCHA
Behavioral Health
