Connections Directory Survey — The Social House

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In-home Therapy Social Groups Facilitated Playdates Community Tagalongs Parent & Family Coaching Formal Assessment

Home Services Testimonials Blog Contact Us Connections Directory

In-home Therapy Social Groups Facilitated Playdates Community Tagalongs Parent & Family Coaching Formal Assessment

connections directory form

All About the Connection Seeker

Name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Email *

If you are a minor or completing this form with the guidance of a caregiver, please enter N/A below. There is a section for caregiver information at the end of the form.

Phone

(###)

###

####

Zip Code *

Preferred distance between me and my connection: *

I am neurodivergent: *

It is important to me that my connection shares my neurodivergance: *

If I answered "yes" to the question above, my specific neurodivergence is/are:

I would like to make connections in the following ways (check all that apply): *

In person

Voice Calls

FaceTime or Video Calls

Text Messages

E-mail

Written mail

Other ways I'd like to make connections (i.e. via video game messaging, etc):

I have one or more special interests. These are interests that I love to incorporate into play and conversation. They make me happy and help me feel safe. I love to talk and think about: *

Examples: Super Mario Brothers, American presidents, railroads, rubber bands, 80s music, Peppa Pig, Disney movies

Other activities I like to do: *

Examples: watch Bluey, paint, draw, jump on a trampoline, go on the swings

I communicate using the following methods (check all that apply): *

Mouth words or speaking

Scripts or Gestalts

Low/Lite tech AAC

Mid/High tech AAC

ASL

Spelling

Vocalization and Gesture

Music

Proximity and Movement

Other ways I can describe my communication: *

Examples: "I have lots of language and have full conversations." "I prefer mouth words and use 1-3 words at a time." "I need extra time to process my thoughts."

If I am an AAC user, the specific form of AAC (i.e. communication book, Proloquo2Go, TouchChat, etc.) that I use is :

It is important to me that my connection shares my communication method: *

I have a physical disability (i.e. cerebral palsy, paralysis, limb differences, etc.):

It is important to me that my connection shares my physical disability:

If I answered "yes" to the question above, my specific physical disability is:

Anything else I would like to share that would help me make a great connection:

Caregiver Information

Name

If the above named is a minor or is completing this form with the support of a caregiver, enter caregiver name below:

First Name

Last Name

Email *

If you entered your own e-mail address above, please type N/A below.

Phone

(###)

###

####

Caregiver or connection seeker (18+) will complete the following section:

Therapist/ Professional Referral Name *

This person will be contacted to verify the identity of the connection seeker.

First Name

Last Name

Therapist/ Professional Referral Phone *

(###)

###

####

I understand that I am responsible for initiating communication with potential connections. *

Yes, I understand.

I give permission to The Social House to share my contact information with potential connections. *

Yes, I give permission.

I understand that I am responsible for my own safety and confirm that the above personal information is correct. *

Yes, I understand.

The following box serves as my digital signature attesting all above information is true. *

Today's Date *

MM

DD

YYYY

Thank you for joining our Connections Directory!

As we gain new members, you will be notified of potential connections via e-mail.

If you have any questions about the directory, please contact us at: connections@thesocialhousela.com

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