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 Inc. 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 Learning 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 Inc. 364 Boston Turnpike Road, Suite 1A Shrewsbury MA 01545

Thank You!

1______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 Jessica Padula MS, CCC-SLP

NEW CLIENT GROUP INTAKE PACKET 2017

(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

2______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 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

3______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 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 at [email protected] 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 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______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 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: 5______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 ______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?

6______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 ______

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

7______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 □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 Sometime Never s 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 Sometime Never s 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”

8______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 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

School Year: Tues-Friday Social Learning 4:15, 5:30 or 6:30 Executive Function Summer Groups Mon/Wed or Tues/Thurs 2:00, 3:00, 4:15, 5:30, 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!

9______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 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:

ABOVE AT BELOW NOT SKILL COMMENTS GRADE GRADE GRADE OBSERVED LEVEL LEVEL LEVEL 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 If Yes, please explain? unique in his interpersonal skills, either in class or out of class? Do you anticipate that this If Yes, please explain? student will encounter more 10______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166 challenges in future school years? How would this student’s peers describe him/her?

11______Speech & Language Specialties Inc. ● 364 Boston Turnpike Rd. Suite 1A ● Shrewsbury, MA 01545 Clinic Services: 508-757-6981 ● www.slspecial.com ● Fax: 508-757-0166