Cooking Club Application

Cooking Club Questionnaire

This information will be treated confidentially.

Step 1 of 4

Client Information

Name(Required)

First Last

Date of Birth:(Required)

Age:(Required)

Name of Person Completing this Form:(Required)

First Last

Relationship to Child:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone(Required)

Email(Required)

Language(s) Spoken in the home:(Required)

Child’s primary language:(Required)

Has your child been formally diagnosed by either a medical professional(s), regional center or school district? If so, at what age and what is the diagnosis?(Required)

Language, Communication, and Executive Functioning Skills

Please take a moment to complete the following tables to provide us with pertinent information related to your child’s receptive, expressive, and pragmatic language skills as well as executive functioning skills. Feel free to elaborate with any examples or clarification as necessary in the comment space below each table.

Please note:
“Maximum Support” indicates a need for either numerous repetitions of information or frequent reminders to complete language related tasks. “Minimal Support” indicates less frequent reminders required for tasks to be completed.

Receptive Language Skills

Maximum Support | Minimal Support | Independent

Demonstrates understanding of grade level content material(Required)

Follows multi-step directions(Required)

Understands jokes and riddles based on word ambiguity(Required)

Understands most common idioms(Required)

Follow complex spoken instructions containing a large amount of information, new vocabulary, and complex grammar(Required)

Understands information that requires inferring or making predictions(Required)

Additional Comments:(Required)

Expressive Language Skills

Maximum Support | Minimal Support | Independent

Uses language effectively for a variety of purposes/situations(Required)

Gives accurate directions to others(Required)

Reports about information gathered in group activities

Can explain relationships between meanings of multiple meaning words

Uses more abstract and specific vocabulary and grammar in conversation

Organizes information for clarity, such as when retelling a personal experience

Uses figurative language in conversation

Additional Comments:(Required)

Pragmatic Language Skills

Maximum Support | Minimal Support | Independent

Verbally or nonverbally greets/acknowledges group members(Required)

Initiates conversation in group setting(Required)

Initiates conversation with individual peer(Required)

Responds to questions and conversational bids in a group setting(Required)

Responds to questions and conversational bids with an individual peer(Required)

Succinctly responds to questions & retells personal experiences in conversation(Required)

Recognizes & responds to nonverbal social cues(Required)

Formulates appropriate questions to gain information or clarification with adults and peers(Required)

Generates appropriate solution to presented problem (social or otherwise)(Required)

Advocates for own needs and preferences(Required)

Clarifies and explains words and ideas when conversation breaks down(Required)

Uses language to persuade and negotiate with others(Required)

Switches language styles to suit the environment, situation, and communicative partner(Required)

Additional Comments:

Executive Functioning Skills

Maximum Support | Minimal Support | Independent

Demonstrates self-awareness & self-regulation skills for impulse control within tasks(Required)

Demonstrates working memory and organization by checking planner/email/homework due dates and executes accurately(Required)

Demonstrates “get ready” (planning) by identifying items required for a given task(Required)

Demonstrates “get ready” (organization) by efficiently gathering necessary items for a given task(Required)

Demonstrates “do” (execution) by following sequential steps to complete a given task(Required)

Demonstrates “do” (attention, time management) by maintaining attention to a task in order to complete it in a timely manner(Required)

Can “multitask” by flexibly shifting between two tasks to complete both(Required)

Demonstrates “get done” (time management, planning, execution) by turning in completed assignments(Required)

Demonstrates situational awareness (reading the room)(Required)

Additional Comments:(Required)

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Cooking Club Questionnaire

This information will be treated confidentially.

Client Information

Referral Information

Academic Information

Cooking Club Specific Information

Language, Communication, and Executive Functioning Skills

Receptive Language Skills

Expressive Language Skills

Pragmatic Language Skills

Executive Functioning Skills