AUTISM KIDS COMMUNICATE

Transcription

1 AUTISM KIDS COMMUNICATE ipad APPLICATION FORM The Autism Community Network is proud to present an opportunity for families raising children with an Autism Spectrum Disorder and severe communication difficulties to be the recipients of an ipad and means for those children to communicate. This is possible thanks to grants received through the St George Foundation and Lions Clubs of Sydney. Each ipad will be fitted with a sturdy cover and loaded with the App ProLoQuoGo, which as a communication program can assist non- verbal children to communicate. An initial hour parent/ carer training program in ProloquoGo will be provided where the ipads will be distributed. A follow up workshop session will be conducted at a later date (to be advised). Priority will be given to members of the ACN with non-verbal children or children with limited verbal capabilities or communication difficulties. Additionally, other families who we can assist in the Sydney metropolitan area will also be eligible and are encouraged to apply. To be considered please complete the application form and submit by 0 th June 0, to the following address: AUTISM KIDS COMMUNICATE Autism Community Network Address: P.O. Box 88 Riverwood NSW 0 Tel: autismcommunity@yahoo.com Successful applicants will be notified by... Regards, Steve Drakoulis President Autism Community Network

2 RESEARCH PROJECT: The ACN (supported by ASPECT) invites all recipients to participate in a research project to assess:. The success of the training program provided. The impact of the ipad and ProloquoGo on the motivation and communication of non-verbal children with autism. More information about the research project, together with a consent form, is provided at the end of this application. The research project is completely optional and a decision not to participate will not impact on the success of your application.

3 Family Details Name: Address: Contact Number: Child Name: Childs Gender: Male Female Date of Birth: Age turning in 0: Diagnosis (ASD): Additional (Co-morbid) Conditions: (may include ADHD/ Cognitive Delays/ Intellectual Disability/ Language Disorder/ Dyspraxia/ Gross or Fine Motor Impairments/ Sensory Processing Disorder etc.) Are you a registered member of the ACN? YES NO Please provide evidence to support the following: Current residential address (utilities invoice etc) Child s diagnosis

4 ABOUT YOUR CHILD Please complete the following to assist our team learn more about your child.. Communication and Expression Communication stage of your child Please circle one number below Non verbal Own Agenda stage (seems to want to play alone, communication largely preintentional, you know mainly through body movements & gestures) Requester stage (reach or take to you to what is needed, understand steps in familiar routines, (may include sounds/ some eye contact/ body movements/few words to calm, echolalia) Early Communicator stage (starts to share interests with you, even by just looking back at you) Partner stage (communicates own interests and experiences, uses past/present/future tense) Verbal capabilities of your child Please circle one number below Noncommunicative Sounds and gestures Single words and phrases Developing sentences. Narrow interests Conversation Full sentences Additional details (optional):

5 . Care/ Educational Setting A B C D E F G H Please indicate (tick the box) where your child is currently placed. Day-care Pre-school Aspect school Other Additional Needs / Autism school Satellite class Mainstream school (infants/primary/high) with support from Aide Mainstream without support Home school I My child does not attend school yet Other details (if relevant):. THERAPY Please indicate the therapy your child currently attends. A Speech Therapy B Occupational Therapy C Applied Behavioural interventions (ABI) ABA etc. D Cognitive therapy E Physiotherapy F Hydrotherapy G Music Therapy H My child does not have external therapy Other details (if relevant):

6 . Current Communication Aids: Please indicate the communication aids that your child currently uses (if more than one is used please indicate EACH one) Communication Device P.C. or Apple laptop/desktop computer Smart phone (iphone, Android) ipad or Tablet Use at home only Use at school or clinic setting only Use at BOTH home and school/clinic Developing Assistance required Competency Competent Can use without adult assistance Current Apps/ programs your child uses: (please list) Unaided communication devices Body language/ Gestures Sign language Aided /assisted communication devices Communication books Communication board Picture Exchange Communication System Other visual picture card system (e.g. Flash cards, board maker cards) Speech generating devices Name device: 6

7 Please list others below not already included : About my child s communication:. My child initiates communication Never Occasionally with a lot of Regularly with some Usually with minimal Always. My child willingly participates in communication: Never Occasionally with a lot of Other (context- needs/interest etc): Regularly with some Usually with minimal Always 6. My child communicates the following: Requests Address basic need ie hunger, thirst etc Get attention Get away (from person/place/object) Go to person/place/object) Use electronic/computer device never Occasionally with a lot of Regularly with some Usually with minimal Always 7

8 6. My child communicates the following: Other (main requests please list) never Occasionally with a lot of Regularly with some Usually with minimal Always Routines: Main routines please list: Shared experiences: Please list main: Emotions Please list main: Other details (optional): 7. How would an ipad change the way your child communicates? Thank you for taking the time to complete this application. 8