Caregiver and Child Developmental Playgroups Survey

Children’s Council invites families to join a free playgroup, designed primarily for children aged birth to three years who have mild to moderate disabilities, learning differences, and/or complex medical needs, along with the parents and caregivers who care for them. Our playgroups are small, supporting approximately 6 children per session, and are held on-site at Children’s Council once a week.

Each family or caregiver will attend one facilitated playgroup per week for three months. These sessions are specifically designed to address your child's unique needs and goals, providing personalized support and opportunities for growth.

With the guidance of a trained early child care specialist, parents and caregivers will learn effective strategies for engaging in play and supporting their child's development, fostering a nurturing environment for both children and their families.
Please help us understand more about your child and family, and how we can best support you.

Reach out to Saeda Fuller if you have any questions:
sfuller@childrenscouncil.org
415-276-2912

Funding for the Caregiver and Child Developmental Playgroups provided by the San Francisco Department of Early Childhood.

Section 1: Adult Caregiver Information (Adult who will be attending program with child)

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* 1. Adult’s First Name:

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* 2. Adult’s Last Name:

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* 3. Adult’s Preferred Language:

English

Spanish

Other (please specify)

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* 4. If you are not the child’s parent/guardian, please provide their contact information below:

First Name:

Last Name:

Email Address:

Phone Number:

Section 2: Child Participant Information

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* 5. Child's First Name:

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* 6. Child's Last Name:

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* 7. Child's Date of Birth:

Date

Section 3: Caregiver Contact Information

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* 8. Phone Number:

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* 9. Email Address:

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* 10. Preferred method of communication. Select all that apply.

Phone call

Text message

The following questions are designed to help us tailor our program to better meet your child's developmental needs. Your responses will be kept confidential and shared only with program staff involved in your child's care. By completing this questionnaire, you consent to the collection and use of this information as outlined.

Section 4: Program Participation and Child’s Developmental Needs

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* 11. Do you have any developmental or medical concerns for your child? If yes, please specify.

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* 12. Has your child been diagnosed with any of the following? Select all that apply.

Autism Spectrum Disorder

Developmental Delay

Speech or Language Impairment

Sensory Processing Disorder

Physical Disability

None of the above

Other (please specify)

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* 13. Is your child currently receiving services for any of the following? Select all that apply.

Early intervention programs

Physical therapy

Occupational therapy

Speech and language therapy

Behavioral support

None of the above

Other (please specify)

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* 14. Are you interested in resources or support for any of the following? Select all that apply.

Child's behavior management

Positive discipline strategies

Educational resources for development

Connecting with other parents/caregivers

None of the above

Other (please specify)

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* 15. We are offering three playgroup session options from January 14, 2025, to March 22, 2025. Please rank the sessions in order of your preferred dates and time.

Tuesdays 10:00am-11:30am

Thursdays 5:00pm-6:30pm

Saturdays 11:00am-12:30pm

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* 16. Please share any additional information that would help us support your child and family during the playgroup.

Thank you for your interest in participating in Developmental Playgroups with Children’s Council! A staff member will contact you to discuss the next steps. If you have questions, please email sfuller@childrenscouncil.org