CARD Social Skills Questionnaire

Thank you for your interest in CARD’s social skills groups. We ask that you complete the form below to the best of
your ability. This form must be returned for your child to remain on our social skills group waiting list. If you
have questions regarding this form, please contact Maraya Bitner at 443-923-7585.

Background Information

1) Child’s name: _________________________________________________________________________

2) ☐ Male ☐ Female
3) Child’s Birthday: _______________________________________________________________________
4) Today’s date: _________________________________________________________________________
5) Address :_________________________________ Zip Code: _______ Phone # :____________________
6) Name of person completing this application: ________________________________________________
7) Relationship to child (mother/father/grandmother, etc.): _____________________________________
8) How did you learn about our groups? CARD provider, KKI provider, Community Event, online
Other:_________________________
9) Please list the services that your child has received in the past:

☐Occupational Therapy ☐Speech Therapy ☐Mental Health Services

☐ Behavioral Psychology ☐ Physical Therapy ☐ Other: _______________________

10) Please list the services currently received:

☐Occupational Therapy ☐Speech Therapy ☐Mental Health Services

☐ Behavioral Psychology ☐ Physical Therapy ☐ Other: _______________________

11) What social skills do you want to be addressed in a social skills group in CARD (Please circle each)?

☐ Initiate a conversation ☐ Turn taking in conversations ☐ Good Sportsmanship Skills

☐ Be successful in a social outing ☐ Other:________________________________________

12) Please list other social activities that your child is currently involved in:

13) Please list any other extracurricular activities (i.e. going to the playground, mall play groups, spending time
with family members etc.) or interests & hobbies:

Provide a typical response that you’d receive from your child for the following questions:

14) How was your day at school?

15) What makes someone a friend?

School Information:
1) Current School Placement:

2) Describe your child’s school based supports:

Self-contained classroom Inclusion with 1:1 aide

Inclusion with supports Inclusion with no support

3) Describe your child’s reading (please circle):

Not Reading Reading Can currently read: Own Name Sight Words Full Sentences

4) Describe your child’s writing level (please circle):

Forms letters appropriately Copies a model Writes independently

Behavior:

1) How long is your child able to sit and attend for a group activity (0 min., 5 mins , 10 mins, 15 mins)?

2) Is there a Behavior Intervention Plan (BIP) being used at school?

3) What motivates your child?

4) Describe concerns that you have about your child’s behavior:

5) Does your child engage in disruptive behaviors such as throwing objects, hitting others, yelling, touching
others, etc?

6) Does your child engage in any aggressive or self-injurious behaviors?

7) What do you do to re-direct the behaviors?

8) Is this effective, does it work?

Thank you for completing this form. Our providers will be able to use this information in an effort to align your
child with the most appropriate social skills group available in our clinic.