Please Note: ALL FIELDS ARE REQUIRED

Full Name

Email

Phone Number

Child's Name

Child's Age (10-18yrs)?

Borough

Previous School/s

Has your child suffered from continual bullying? If so, how?

Has your child been known to bully or intimidate others? If so, how?

Does your child have social difficulties/differences? If so, what are they?

Does your child have learning difficulties/differences? If so, what are they?

Does your child have communication difficulties/differences? If so what are they?

Does your child attend any other groups? If so, how many and are they successful?

What are common triggers for your child’s anxiety?

What are common triggers for your child’s anger?

What strategies help reduce your child’s anxiety and/or anger?

Is your child likely to follow rules? What rules may they not understand?

Is your child likely to damage furniture or resources? If so, in what way?

Is your child likely to have frequent angry outbursts? If so, what would they consist of?

Is your child in need of 1:1 supervision? If so, what for?

Please indicate any other relevant information here …

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