PARTICIPANT INFORMATION FORM

Transcription

1 Demographic Information PARTICIPANT INFORMATION FORM 1. Name of Participant: 2. Date of Birth (mm/dd/yyyy): 3. Gender: Male Female Transgender I chose not to disclose 4. Participant s Home Phone: Cell Phone: 5. Participant s 6. Are you your own legal guardian? Yes No *If no, please provide the following information: Legal Guardian Name: Relationship to Participant: Parent Sibling Other: Contact Phone #: 7. Emergency Contacts: Who may we contact in the event that you have a health emergency while engaged in Hussman Center programs or activities? (you must identify two people) Contact 1 Name: Relationship to Participant: Parent Sibling Other: Contact Phone Numbers: Contact 2 Name: Relationship to Participant: Parent Sibling Other: Contact Phone Numbers: 1

2 8. Street Address: City: State: Zip: County of Residence: 9. Ethnicity (select all that apply): African American American Indian/Alaskan Native Asian Caucasian Hispanic/Latino Native Hawaiian/Other Pacific Islander I chose not to disclose my ethnicity Medical and Health Information- Allergies/Sensitivities Information 10. Do you believe you have Autism or Asperger Syndrome? Yes No *Check those that apply: Formally diagnosed Self Diagnosed Not sure 11. Please mark any and all other identified diagnoses that may influence your participation in our programs: ADHD/Attention Disorder Anxiety Bipolar Disorder Depression Dyslexia Epilepsy Hearing Impairment Language Disorder OCD Visual Impairment Learning Disability Physical Disability Other: 12. Please list any other medical/health conditions that may impact your program participation: 13. Please list all medications you take that may have an impact in any way on your alertness, behavior, or overall health. This information is important for us to have for planning for your participation in Hussman Center programs and in the event of an emergency situation: 2

3 14. Do you have any food/environmental allergies? Yes No If yes, please check all that apply: Food Allergens: Dairy Eggs Fish/Shellfish Gluten Nuts/Peanuts Soy Wheat Other: Environmental Allergens: Bees/Insects Cigarette Smoke Dust Grasses Latex Mold/Mildew Pet Dander Pollen Other: 15. If you are allergic to the items above, please describe your reaction and any procedures that need to be taken: 16. If you are allergic/sensitive to any of these irritants, do you carry an Epi-pen and/or an inhaler on your person? Yes No Educational Information 17. Check all that apply Completed high school with a diploma Completed high school with a certificate Completed GED Attended some college Completed 2 year degree Completed trade school Completed some 4 year college degree Completed graduate degree Other 18. Would you like to continue your education? Yes No What would you like to study? Volunteer and Work Experience 19. Are you currently working or volunteering? Yes No If yes, where? Have you volunteered or worked in the past? Yes No 3

4 If yes, check all that apply: During high school After high school Part time Full time Within the last year One job More than one job More than 5 jobs Have you had a job position for which you received pay? Yes No Describe: 20. Would you like to work in the future? Yes No What is your dream job? Challenging Situations 21. What situations are most challenging for you, and what helps when these situations occur? For example: Loud noises often scare me and cause me to withdraw from the group, it helps me when I understand where the noise is coming from; or, I often feel excited when I meet new people, so I will yell to show my excitement. Please share helpful tips: what signs/signals indicate you are having a hard time? What strategies help you? Interests and Strengths 22. Please share some interesting facts about yourself: 23. What are your strengths? 4

5 24. Please list some of your special interests and other activities you like to do for fun: Accommodations 25. My preferred communication mode(s) are: (Check all that apply): American Sign Language (ASL) Electronic Device/Assistive Technology Gestures Picture Communication System Speech Visual Other: 26. What other supports and accommodations are helpful to you? (For example: pictures of the activity, task steps, social stories, mobility devices, etc.) Hussman Center Experiences 27. Have you ever attended a program at the Hussman Center for Adults with Autism? Yes No If yes, what programs have you participated in? Other 28. Please add anything else that you would like to share with us about yourself or your interests and goals so that we can consider how we can best support you in having an outstanding experience at the Hussman Center. 5