THE LANGUAGE AND BEHAVIOR CENTER

Social Skills Groups

Services to support your child's social-emotional development

For New Clients

Your Name

Relationship to Child

Email Address

Phone Number

Insurance Type

Diagnosis

Pediatrician's Name

Pediatrician's Phone Number

Child's Name

Child's Date of Birth

Address

Insurance ID

Name of School (if in school)

Services received in school:

Reason for Requesting Services

Current Medications & Dosage (if applicable)

Previous Experience with Social Skills Groups (if any):

Are you able to travel to Silver Spring, MD one evening per week?

Other Information: Please include any information you think we should know about your child that we haven't asked you about in this intake form.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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