APPLICATION. Fall / Spring / Summer. Emory Autism Center. Emory University School of Medicine Department of Psychiatry and Behavioral Sciences

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1 Emory Autism Center Emory University School of Medicine Department of Psychiatry and Behavioral Sciences mylife Fall / Spring / Summer APPLICATION Emory Autism Center 1

2 APPLICATION PROCESS Emory Autism Center mylife program Application Steps (1) Please contact the appropriate mylife Educational Coordinator to schedule an Initial Consultation. (2) Please print this application, complete, and submit to the appropriate Educational Coordinator BEFORE your appointment via . NOTE: application must be submitted BEFORE Initial Consultation so staff may review. (3) Attend Initial Consultation with mylife Educational Coordinator. Consultation is used to get to know you and to discuss your own wants and needs. We will share information about the program and provide tentative notification as to whether the mylife program would be appropriate for you. Application Selection (1) All applications will be screened and reviewed by the Emory Autism Center s Adult Program team. Final decisions regarding admittance in to the Emory mylife program will be made by Dr. Joseph Cubells, the Director of Adult Services. (2) Admission decision will be based on the following criteria and may include additional factors which will be discussed with you during the Initial Consultation: - The applicant must have an Autism Spectrum Disorder. - The applicant must be able to communicate (whether verbally or via a communication system). - The applicant must be able to take care of their own self-care needs. - The applicant must demonstrate the desire to attend the Emory mylife program and participate in all aspects of the program (including workshops and classes which may run from 30 minutes to an hour in length depending upon the group). - The applicant must demonstrate the ability to accept and follow reasonable rules, behave respectfully toward others and adhere to Emory University s visitor s policies. *Please note that the Emory mylife program does not have the personnel to supervise group members with challenging and oppositional behaviors. Emory Autism Center 2

3 Please check semester applying for: Fall 2018 Winter/Spring 2019 Summer 2019 Signature denotes all information is correct: Student Information Date: Name Street Address City County State Address Cell Phone Age DOB / / Family Information Student lives with: Alone with a Roommate Both parents Mother Father Other: (please note relationship): Parent/Legal Guardian #1: Name Address Relationship Cell Phone Parent/Legal Guardian #2: Name Address Relationship Cell Phone Financial Resources: (circle all that apply) Self SSI Waiver Vocational Rehabilitation Family Member: Other: Emory Autism Center 3

4 Education History / Information NOTE: This page of information may be shared with relevant presenters High School Name City State Diploma type: Regular Ed Special Ed Post-Secondary Institution (college, technical programs, etc.) Name City State Major Years Completed? Yes No (if not, why?) Name City State Major Years Completed? Yes No (if not, why?) Employment History Name of Business / Employer Position / Responsibilities Dates Reason for leaving Extracurricular and Volunteer Activities Activity Position / Responsibilities Dates Reason for leaving Emory Autism Center 4

5 Medical History Diagnosis: (Note: the Emory Autism Center is not able to dispense medication to mylife participants) Please list any current medications and what they are taken for: Name of Medication What it is for How Often Side Effects Are you independent in administering your medication on your own? YES NO Please list any allergies: Allergy Symptom Treatment Please list any chronic conditions (seizures, migraines, etc ). Be sure to include any conditions that will affect your participation in classroom, social or recreational activities: Condition Treatment Situations that may aggravate Areas of Support Service Providers (circle all that apply): Psychiatrist Psychologist Therapist/Counselor Behavioral Therapist OT/PT Challenging Areas? Have you ever been physically aggressive towards someone? NO YES - most recent time: Have you ever thought about/tried hurting yourself or killing yourself? NO YES - most recent time: Sensory Areas? Are there any things you are highly sensitive towards? NO YES - please list below: Emory Autism Center 5

6 Communication Communication (select all that apply) Fully Verbal Verbal, but does not like to talk Sign Language Pictures PECS Augmentative System Nothing Challenges with non-verbal communication skills (gestures, body language, eye contact, facial expressions) Leisure What are your favorite things to do? (please note specific things below) (1) (2) (3) (4) (5) Social Relationships How do you spend your time if you re not at school/work? (please note specific things that you may do with others) Friends Clubs/Groups Dating With Spouse Social Media (online friends?) (1) (2) (3) (4) (5) Thank you for taking the time to fill out our mylife application. We look forward to meeting with you! Emory Autism Center 6