Escape Room Social Skills Questionnaire - Is this right for your child?
Thank you for your interest in The Escape Room Social Skills Program through the Simcoe County District School Board (SCDSB). This questionnaire will provide key information that will help us determine if the Escape Room Program may be a good fit for your child and family. Upon submitting the questionnaire, you will be contacted by Crystal Gronc. If you have any questions please contact Crystal, ASD After School Social Skills Program Coordinator through email at cgronc@scdsb.on.ca
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How did you find out about the Escape Room Social Skills Program through the SCDSB? *
Name of child (first and last): *
Gender: *
Age of child: *
What grade is your child in as of September 2021?
What school does your child attend?
Parent/Guardian name (first and last): *
Email address: *
Phone Number (home): *
Phone Number (cell): *
Address (street# and/or unit#, street name, city, postal code): *
Additional Parent/Guardian name (first, last) if sharing custody, etc.
The Escape Room social skills program supports social skills development using problem-solving, critical thinking and teamwork for children in elementary or seconday school. Is this child in school and would this program be of interest to his/her family? *
There is a parent component of the Escape Room Program which requires one parent to attend on a consistent basis. Would at least one parent be available to consistently attend the program with the child? *
Does the child want to have friends and learn new strategies? Would he/she/they be motivated to learn how to make new friends and attend the class? 1= extremely resistant, 7=Is open to being helped and wants desperately to improve *
Extremely resistant
Open to being helped and wants desperately to improve
Is the child's family be able to attend the Escape Room Program using a virtual platform (e.g. Zoom)? e.g. has at least one device at home and can access the internet. *
What are the child's favourite activities or special interests? *
What road block(s) does the child have making friends? Please check off all options that apply *
Required
Does the child have any type of psychological or medical diagnosis? Please check off all options that apply *
Required
How severely affected is the child's communication? This will help us understand his/her language and conversational abilities. 1= Uses echolalia, brief sentences or single words, needs frequent adult support, very limited verbal expressive abilities, 7=Mainstreamed in advanced academic classes, socially awkward, trouble making/keeping friends *
uses echolalia, brief sentences or single words, very limited verbal expressive abilities
mainstreamed in advanced academic classes, socially awkward, trouble making/keeping friends
What educational classroom setting is the child currently placed in? *
Academically, is the child on an adapted or modified program below grade level? *
Does the child have any aggressive behavioral difficulties at home or school? *
Does the child have a group of friends at school? *
Does the child have play dates with peers or have friends come over? *
Does the child participate in any extra-curricular activies (or have they)? *
Which of the following skills does the child require assistance with? Please check off all options that apply *
Required
Are you comfortable with having your contact information shared with the program provider to connect about future support and programs?
Clear selection
Any other questions or comments?
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