Bloom Pediatrics
Nature. Nurture. Bloom.
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Friendship Garden follow-up survey

šŸŒ±Support social thinking and inspire friendships through gardeningšŸŒ±

During each group meeting, your child will learn social thinking concepts and practice self-regulation techniques while planning and creating a garden filled with vegetables, flowers, and succulents.

friendship garden follow-up survey

FRIENDSHIP GARDEN FOLLOW-UP SURVEY *
My child participated in the following group:
PARENT INFORMATION
Parent Name *
Parent Name
Phone *
Phone
CHILD INFORMATION
Child Name *
Child Name
Date of Birth *
Date of Birth
FOLLOW-UP GROUP SURVEY
This information will help us measure your childā€™s progress and overall group effectiveness. Please rate how much you agree or disagree with the following statements.
1. My child is able to behave appropriately in a group (i.e. follows directions, keeps a calm body, stays seated, etc.) *
2. My child is able to initiate conversation with peers. *
3. My child is able to engage in play with a group of peers. *
4. My child is able to tolerate frustration. *
SOCIAL PARTICIPATION
The following are taken directly from the Sensory Processing Measure by L. Diane Parham, Ph.D., OTR/L, FAOTA, and Cheryl Ecker, M.A., OTR/L Please answer the questions based on your childā€™s typical behavior during the past month.
1. Does your child play with friends cooperatively (without lots of arguments)? *
2. Does your child interact appropriately with parents and other significant adults (communicates well, follows directions, shows respect, etc.)? *
3. Does your child share things when asked? *
4. Does your child carry on a conversation without standing or sitting too close to others? *
5. Does your child maintain appropriate eye contact during conversation? *
6. Does your child join in play with others without disrupting the ongoing activity? *
7. Does your child take part in appropriate mealtime conversation and interaction? *
8. Does your child participate appropriately in family outings, such as dining out, or going to a park, museum, or movie? *
9. Does your child participate appropriately in family gatherings, such as holidays, weddings, and birthdays? *
10. Does your child participate appropriately in activities with friends, such as parties, going to the mall, and riding bikes/skateboards/scooters? *
ADDITIONAL INFORMATION
Would you like us to contact you to discuss any information you provided in this survey? *