Social Skills Program Intake Form G.I.F.T. Social Skills Placement Request If you are interested in learning more or requesting placement for your child, please contact our team or complete the form below. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Caregiver NameFirstLastCaregiver PhoneHow old is your child?Does your child nap?Developmental MilestonesCan your child request needs using 3 or more-word sentences?YesNoYesNoCan your child feed himself/herself without assistance?YesNoYesNoHygieneIs your child potty trained?YesNoYesNoDoes your child wear pull ups or diapers?YesNoYesNoMedicalDoes your child have a diagnosis/diagnose?YesNoYesNoDoes your child have a history of seizures?YesNoYesNoDoes your child have any allergies?YesNoYesNoDoes your child currently receive medical services such as therapies (i.e., ABA, OT, Physical, Speech, etc.)?YesNoYesNoEducationIs your child placed in a school, daycare, or an educational program?YesNoYesNo seizures? assistance? using Has your child been kicked out or removed from a school, daycare, or educational program?YesNoYesNoBehaviorsDoes your child display sensory barriers (i.e., sound, touch, light, food, clothing, etc.)?YesNoYesNoDoes your child engage in challenging behaviors when told “no” (i.e., longer episodes of crying, tantrums, throwing or slamming items, kicking, screaming, hitting others, etc.)?YesNoYesNoDoes your child often throw items?YesNoYesNoDoes your child often engage in hitting or kicking others?YesNoYesNoDoes your child engage in self injurious behaviors (i.e., hitting self, head banging, hair pulling, biting, eye poking, gaging self, squeezing or pinching self, scratching, etc.)?YesNoYesNoLanguage and CommunicationDoes your child respond to yes/no questions to indicate a preference?YesNoYesNoDoes your child verbally respond to greetings and farewells?YesNoYesNoExpressive LanguageDoes your child ask questions using 3 or more words?YesNoYesNoHow did you hear about us?Online Search (website)FlyersDoctor’s OfficeFriend/Family MemberEmailsOtherOtherTotal ScoreSubmit Office17407 Bridge Hill Court BC Tampa, FL 33647 Call 813-632-9250 Emailinfo@giftabatherapy.com
