We Are Very Excited That You Are Interested in Enrolling Your Child in Our Therapy Groups

Dear Parent,

We are very excited that you are interested in enrolling your child in our therapy groups at Speech & Language Specialties. In order to determine what group would best meet your child’s needs we need to gather information from you about him/her. Please complete the enclosed forms and return to us promptly so we can contact you to set up an intake interview if needed.

Groups are arranged according to maturity, age, cognitive level and level of social cognition. Please note that a significant amount of effort goes into the organization of these groups. To ensure the highest level of progress for your child and because other clients are dependent on the commitment it is important that you are committed to participating in the duration of the group.

Program Basis

We teach our clients how to be more successful in social settings. Participants will acquire the social skills they need to interact with others as well as the ability to think socially.

At SLS, we teach the thoughts behind the social skills, helping our clients to see how their actions and behaviors influence others. Many of the concepts and activities we use in therapy are based on the work of award-winning experts in the areas of Social Thinking ® and social communication, including Michelle Garcia Winner and Leah Kuypers (The Zones of Regulation ®) as well as incorporate language enriched activities that will break down and teach abstract social-thinking to students.

Participation may be helpful for children whose peer relationships are hampered by issues related to Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Nonverbal Learning Disorder (NLD), learning problems, language delays, and auditory processing disorders.

Social Communication Therapy Groups Will Focus On:

SOCIAL CONNECT LEVEL I AND II

Expected vs. Unexpected

Emotional Regulation

Thoughts: We All Have Them!

Flexible Thinking

Perspective Taking

SOCIAL SUCCESS TWEENS AND TEENS

Understanding Nonverbal Language

Understanding Hidden Social Rules

Emotional Regulation

Problem Solving and Negotiating

Executive Functions

Please send all information to:

Speech and Language Specialties

364 Boston Turnpike Road, Suite 1A

Shrewsbury MA 01545

Thank You!

Jessica Padula MS, CCC-SLP

NEW CLIENT GROUP INTAKE PACKET 2014 - 2015

(Please make sure all forms are completed and signed prior to submission. Include this checklist with your application packet).

□ Contact Form

□ Video and Audio Permission

□ Policies & Procedures

□ Parent Assessment

□ IEP/Report(s)/Outside assessments (if available)/any other information which will give us a better understanding of your child and his/her strengths and challenges

CONSENT TO USE VIDEO OR PICTURED IMAGE & AUDIO RECORDING

**This form must be signed in order for you/your child to participate in the program**

The use of video, picture image and audio recordings are an essential component to our social groups. We must be allowed to use these types of recordings in order for you/your child to participate in our program.

Please check the first two boxes to indicate that you will allow these recordings and wish to participate in our program:

□ I give permission for Speech & Language Specialties to use the image of my child within the clinic setting for therapeutic purposes.

□ I give my permission to audio tape my child for clinical purposes.

Occasionally in the course of recording the sessions we will capture an interaction that accurately illustrates a particular strategy or skill for a training/conference setting. The video will be used to educate fellow parents and professionals about how to apply therapy techniques that are being discussed.
Check only if you are comfortable with this option:
□ I give permission for video or pictures of me/my child to be used in both clinical & conference settings.

______

Signature Print parent/guardian name

______

Print Client Name Date

POLICIES AND PROCEDURES

Enrollment and Scheduling in Groups:

We group students with peers that function similarly to your child in his/her cognitive, perspective taking, social language, reading, writing and auditory processing abilities. Finding common times for similar students to be scheduled can be a difficult puzzle to solve. To help with the process we encourage you to provide as many possible times and days to allow the most options when scheduling. This significantly increases the chances that your child will be placed in a group. Please read the below information closely as it has changed.

Attendance and Cancellation Policy for Groups:

Please note that a significant amount of effort goes into the organization of these groups. To ensure the highest level of progress for your child and because other clients are dependent on the commitment it is important that you are committed to participating in the duration of the group.We allow 1 excused absence for no charge, reasons for missed session may include illness, special events, vacation etc. Additional missed session will be billed at a flat rate of $50 per session.

If you need to cancel a scheduled appointment (individual or group), please notify the SLS administrative office at least 24 hours in advance of the appointment by emailing our office administrator Carrie Robbins or calling (508)757-6981.

Family Involvement:

Parents and caregivers are encouraged to attend the last 10 minutes of each therapy session to explore with the therapist the new ideas learned during the session. Each client’s growth and progress depends on continued exposure and carryover in outside environments by the adults and professionals supporting them. It is central for these team members to learn new concepts, vocabulary, and strategies along with the child/client.

Applications:

Please fill out prior to initial intake.Remember, the more time slots you make available for us to choose from, the more likely it will be that we are able to place your child in our clinic.

Fee Schedule for Individual Therapy Services

60 minute - Speech, Language, and Social Learning$105.00

45 minute - Speech, Language, and Social Learning$85.00

45 minute – Music Therapy$80.00

Fee Schedule for Social Communication Groups:

Initial Group Intake Screening$85.00 (One-time fee)

Dyad (2 students) $95.00 per student

3 students $85.00 per student

4 +students $75.00 per student

CONTACT FORM

Date______

Client Name: ______Birth date______

Insurance Provider: ______

Insurance #: ______

Mother’s Name: ______Occupation: ______

Address: ______City: ______Zip: ______

Home Phone:______Cell #:______

Work#:______Email:______

Father’s Name: ______Occupation: ______

Address: ______City: ______Zip: ______

Home Phone:______Cell #:______

Work#:______Email: ______

SIBLINGS:

Name and Age______Name & Age______

Name and Age______Name & Age______

School Name and District/City:______

PLEASE LIST ANY FOOD ALLERGIES OR DIET RESTRICTIONS FOR YOUR CHILD:

______

Needs Epi-pen: Yes / No

PLEASE PROVIDE EMERGENCY CONTACT INFORMATION:

______

Print Name of Emergency Contact Phone

______

Relationship to client

PARENT ASSESSMENT

Child’s Name/Nickname: ______

Current Educational Setting:

□Public School□Private School□ Home Schooled □Combination

Current Services: □OT □Speech □Specialized Classroom □ 1:1 Aide □Other:______

Diagnostic label:

□Autism Spectrum Disorder (ASD) □Pervasive Developmental Disorder (PDD)

□Asperger Syndrome□Non-Verbal Learning Disorder (NLD)

□Attention Deficit-Hyper Activity (ADHD) □Attention Deficit Disorder (ADD)

□Expressive/Receptive Language Delay□Anxiety

□No Diagnosis □Other ______

What are your current concerns about your child’s performance at school?

______

What are you current concerns about your child’s performance at home?

______

Please list the classes or topics you child does BEST in school: ______

Please list the classes or topics your child struggles the most with at school:

______

Is the child aware of the problem?

______

Has any other speech-language specialists seen your child? Who and When? What were there conclusions/suggestions? ______

______

Any Hospitalizations? If yes, explain. ______

______

Is the child taking any medication? If yes, identify. ______

Receptive Language Development (Processing): Check all that apply

______Processes information quickly

______Uses new concepts readily, incorporates new vocabulary into communication

______Learns new concepts with repetition, needs cues to use new vocabulary. Visual and physical

cues helpful

______Delay in response time

______Understands communication when paired with visual and physical prompts.

______Very concrete comprehension

______Child has difficulty understanding the concepts and language introduced – requires visual and/or

physical prompts to understand message.

Expressive Language Development: Check all that apply

_____ Advanced vocabulary and sentence structure.

_____ Age expected vocabulary and sentence structure.

_____ Slightly delayed vocabulary and sentence structure.

_____ Significantly delayed vocabulary and sentence structure.

BEHAVIORS: PLEASE CHECK BEHAVIORS THAT DESCRIBE YOUR CHILD. PLEASE CHECK ALL THAT APPLY.

□Motivated□Anxious□Externally distracted

□Impulsive Oppositional□Aloof/internally distracted

□Rigid (my way or the highway attitude)□Physically aggressive

□Verbally aggressive to peers or adults (describe) □Withdrawn (may hide or emotionally shut down when upset)

BASED ON YOUR OBSERVATIONS, RATE YOUR CHILD’S USE OF THE FOLLOWING SKILLS:

My child uses this skill… / Always / Sometimes / Never
Listens when you or others talk to him/her
Uses body language to communicate
Interprets body language
Uses facial expression to communicate
Uses inflection/tone of voice to communicate
Interprets inflection/tone of voice
Stands appropriate distance from people
Uses appropriate eye contact
Uses appropriate voice volume
Accepts ideas during play
Gives ideas during play
Initiates play
Solves conflicts without an adult
Plays by the rules
Ok with timed tasks/activities
Wins like a good sport
Initiates greetings
My child uses this skill… / Always / Sometimes / Never
Introduces self to others
Introduces other people
Engages in small talk
Initiates conversation
Shares related events stories
Keeps conversation going
Ends conversation appropriately
Stays on topic
Notices disinterest
Gives compliments
Imitates peers
Responds to greetings
Reacts appropriately to others’ emotions
Shows assertion when appropriate
Says “I’m sorry”
Accepts apologies
Inquires about a new friends
Shows interests in fads
Tells jokes, listens/reacts to jokes
Laughs appropriately
Asks for help, accepts help, offers help
Deals with teasing
Expresses anger appropriately
Interprets a situations (make inferences)
Takes another’s perspective
Makes predictions about others’ reactions
THERAPY / DATES/TIMES/DURATION / 1ST Time Choice / 2nd Time Choice / 3rd Time Choice
Social Communication
Executive Function Groups / Tuesday through Friday
4:15, 5:30 or 6:30

Additional Questions:

What does your child like to do? ______

What does your child dislike? ______

Is your child currently active in any extracurricular/recreational activities? ______

Therapy goals and additional comments or concerns: ______

Thank you for taking the time to complete this form. It is greatly appreciated and will be helpful in completing your child’s intake process here at SLS. We look forward to working with you and your child!

TWEENS AND TEENS

SOCIAL SUCCESS!

PARENTS PLEASE HAVE YOUR CHILD’S EDUCATOR/THERAPIST FILL THIS OUT

Dear Professional,Date: ______

Name of Student: ______

is being considered for placement in a group at our practice. It would be greatly appreciated if you could complete the below information regarding this student based on your own experience.

Your Name: ______Grade of Student: ______

Relationship to the student: ______

Please check off where you feel how this person does in your setting in the following areas:

SKILL / COMMENTS / ABOVE GRADE LEVEL / AT GRADE LEVEL / BELOW GRADE LEVEL / NOT
OBSERVED
Math
Reading Decoding
Reading Comprehension
Written Expression
Participating as part of the large group during class discussion/lecture
Participating as part of a small group in class
Making and keeping friends during free time
Ability to ask for help in class
Organizational skills while in class
Organizational skills from home to school and back
Does this child stand out as unique in his interpersonal skills, either in class or out of class? / If Yes, please explain?
Do you anticipate that this student will encounter more challenges in future school years? / If Yes, please explain?
How would this student’s peers describe him/her?

1

______

Speech & Language Specialties● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545

Clinic Services: 508-757-6981 ● ● Fax: 508-757-0166