Child's Name: *REQUIRED*

Age and Date of Birth *REQUIRED*

Grade in School: *REQUIRED*

School or program your child attends: *REQUIRED*

Does he/she have a 1:1 aide? *REQUIRED*

Would he/she need 1:1 support in this program? *REQUIRED*

Is the child receiving services through OMRDD? *REQUIRED*

If so, does the child have a CSS plan? *REQUIRED*

Parent/Guardian Names: *REQUIRED*

Address: *REQUIRED*

City/State/Zip Code: *REQUIRED*

Home phone: *REQUIRED*

E-mail address: *REQUIRED*

Medical Diagnosis or Disability Category *REQUIRED*

Emergency Contact Information (contact, relationship, phone): *REQUIRED*

Permission to Administer First Aid: *REQUIRED*

1. Identify specific social skills or challenges in regulating emotions or behaviors that you believe are most important for your child to develop. *REQUIRED*

2. Describe briefly how your child communicates, particularly if he or she has delays or difficulties in spoken language. *REQUIRED*

3. What are your child's strengths? *REQUIRED*

4. What are your child's favorite activities, special interests, talents or hobbies? *REQUIRED*

5. Are there any behaviors, sensitivities or triggers that the group facilitators need to know about in order to create a successful experience for your child? *REQUIRED*

6. Will your child need special accommodations or clear limitations when structuring sessions? If so, provide suggestions for addressing these behaviors. *REQUIRED*

7. Is your child able to participate in a group activity for a half hour without breaks? *REQUIRED*

8. What is the size group your child is accustomed to working in successfully? *REQUIRED*

9. Provide any information that will assist the group facilitator in structuring the sessions for the child's greatest success (e.g. visual schedules, short breaks every 15 minutes, behavior management sessions). *REQUIRED*