Kinark Group Interest Form

Information Collection Notice: This intake form is used to determine clinician assignment, suitability of service, and prepare for our initial contact with you. The information collected will be stored in your child’s confidential client record and will only be accessible by those actively involved with your service.

Kinark Group Interest Form

Please select the group you are interested in:*
- Select All
- Ready, Set, Play!
- Kids Klub
- Friendship Boot Camp
- PEERS® for Teens: Friendship Boot Camp
- PEERS® for Teens: Dating Boot Camp
- PEERS® for Teens: Bully Proofing Boot Camp
Please select the delivery format you are interested in:*
- Virtual (Online)
- In-person
- Both virtual and in-person
If you are interested in in-person groups, please select the location(s) you are interested in:*
- Select All
- Richmond Hill
- Barrie
- Oshawa
- Markham
- N/A - not interested in in-person groups
Don’t see a suitable group? Let us know what you’re looking for here:
Parent and Caregiver Information
Parent First Name:*
Parent Last Name:*
Parent Email:*
Parent Phone Number:*
Preferred contact method:*
- Phone
- Email
Parent Address:*
If another caregiver (other than the parent completing the screening) may be involved, what is their full name, relationship to the child, contact information, and any other relevant details?
Consent
By completing this form, you certify that you are the primary caregiver of the child/youth which this form is being completed for. If you are not the primary caregiver, you confirm to have consent from the primary caregiver to complete this form. If you are not the primary caregiver or do not have consent from the primary caregiver and are looking to inquire about our services, please complete our 'Request a Consultation' form.
Child/Teen Information
Child First Name:*
Child Last Name:*
Date of Birth (DD/MM/YYYY):*
Age:*
Siblings:*
- Yes
- No
If "Yes", please specify the sibling age(s):
Current School:*
School Board:*
Grade:*
Placement Type:*
- Mainstream (no support)
- Mainstream (with support)
- Part-time learning centre
- Community/county - Autism Spectrum Disorder (ASD)
- Community/county - developmental disabilities
- Other
If "Other", please specify:
Parent/Caregiver Participation
I am able to (please select all that apply):*
- attend a parent orientation session for an overview of the group and to review group expectations
- attend ongoing parent education sessions and help my child with homework activities to practice the skills learned
Child/Teen Profile
My child/teen is (please select all that apply):*
- motivated to participate in a group
- motivated to interact with his/her peers (vs. avoiding social interactions)
- able to engage in reciprocal conversation through technology (i.e., typing, chats, etc.)
Communication (please select one that best describes your child):
- Speaks fluently in full sentences and can discuss events that happen in the past or future
- Speaks in full sentences but may need support with extended discussions or reciprocal conversations
- Speaks in two or three word phrases
- Speaks in single words
- Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device)
- Has no formal mode of communication (e.g., cries, pulls, points, pushes)
Independence and Attention (please select one that best describes your child):
- Can follow along with a group independently for 45 to 60 minutes (with breaks)
- May need some additional parent/adult prompting and/or modeling
- Will require one-to-one support to attend and/or participate
Behaviours that may be disruptive to group participation (please select all that apply):*
- Aggression or property destruction (e.g., throwing, swiping, kicking and punching)
- Self-injury
- Vocal aggression (e.g., swearing, racially/culturally inappropriate comments)
- Other
If "Other", please specify:
Please list any health conditions that may interfere with your child's learning (e.g., seizure disorder, anaphylaxis, anxiety, depression):*
What are some of your child/teen’s topics of interest or preferred activities?*
Do you have any suggestions (tips and tricks) to improve your child/teen’s success with a group program?*
Considerations for Group Learning
Has your child participated in group learning previously? Please select all that apply.*
- In-person groups
- Virtual groups
- None
If "Yes", who provided the service?
If "Yes", what were the what were the goals of the group, and in your opinion, were the goals met?
If "Yes", how was your experience (what did you like and what could have been done differently)?
What are some of your child/teen’s needs? Please select all that apply.*
- Group Learning Skills (e.g., attending to group activities, responding together with a group, following multiple instructions in a group)
- Communication / Conversation Skills (e.g., initiating, maintaining and ending conversations, making comments, staying on topic, changing the topic)
- Social Problem Solving & Conflict Resolution (e.g., responding appropriately when in a disagreement with a friend)
- Social Connections (e.g., increasing get-togethers, increasing friends at school/community, choosing appropriate peer groups)
- Decrease social isolation and dealing with bullying and/or teasing
- Cognitive Flexibility (e.g., showing flexibility when things do not go as planned)
- Self-Regulation / Managing Emotions (e.g., responding appropriately to mistakes made by self or others, asking for and/or accepting help when needed)
- Perspective Taking (e.g., recognizing how others are feeling and responding appropriately)
Please share any additional information or comments/questions that you may have:
Technology Requirements
Please complete this section if you are interested in virtual groups.
Do you have adequate internet connectivity (i.e., high-speed internet with sufficient bandwidth) and access to appropriate technology (e.g., a computer/laptop/tablet) which supports video conferencing (i.e., have a microphone, speakers, and a webcam)?
- Yes
- No
Would you be using a password-protected, secure internet connection to join the group (vs. public or unsecured Wi-Fi)?
- Yes
- No
How did you hear about us?*
- Informal networking (e.g., friends, family, support group)
- Physician or other medical professional
- Social media (e.g., Facebook, Twitter)
- Community agency or organization
- Google or other search engine
- Ministry website/letter
- Brochure/flyer/poster
- Online advertisement
- Kinark newsletter
Do you want to be added to our mailing list to receive information about our programs and services?**
- Yes
- No
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Kinark Group Interest Form

Kinark Group Interest Form

Parent and Caregiver Information

Child/Teen Information

Parent/Caregiver Participation

Child/Teen Profile

Considerations for Group Learning

Technology Requirements

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