Social Skills/Support Group Application
Today's Date:
Name:
Address:
City:
State:
Zip:
Phone:
(
)
E-Mail
Gender
Male
Female
Is applicant in school?
Yes
No
If yes, give school and district name
Date of last IEP
If no, give date of graduation
Is applicant receiving any post school services?
For example, CMH, MRS
Has applicant had a Person Centered Planning Meeting?
Yes
No
If yes, give date
Is applicant employed?
Yes
No
If yes, where?
Where is applicant living?
How long have they lived there?
Does the applicant have a support person?
Yes
No
If yes, give name and phone number
(
)
Does applicant have any physical or health problems?
Yes
No
If so please list
Does applicant have any social or behavioral issue?.
Yes
No
If so please list
Please indicate below why the applicant would like to join the social skills group.