Meet, Play Repeat: Making New Friends Can Be Fun

Please complete and submit the form below. We will review your information and evaluate your child's fit for the upcoming group. We will contact you shortly after submission. If you have any questions, please call our administrative team at (215) 579-2180 during regular business hours.

Screening Form

General Information

Child Information

Child's Name

Child's Age

Parent 1 Information

Parent 1 Full Name

Parent 1 Address:

Country/Region

Address

City

Zip / Postal code

Phone

Best contact phone number (where you can be reached during the day)

Parent 2 Information:

Parent 2 Full Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Best contact phone number (where you can be reached during the day)

General Questions

You and the child's other parent are?

Together

Divorced

Separated

Other

If divorced, please upload your current custody agreement – this is necessary for consent to treatment.

Please list any and all food allergies.

Is your child currently receiving any therapeutic services? If so, please list with whom and where these services are being provided.

Please write "NA" if your child is not currently receiving services.

Does your child have any diagnoses?

What are your child’s strengths?

What are your child’s areas of interest?

What does your child engage in for fun?

Does your child have siblings?

Sensory Information

Does your child struggle touching certain textures of fabric? If yes, please explain.

Is your child sensitive to sound? If yes, please explain.