KINGSTON AFTER SCHOOL ABA PROGRAM PART A: APPLICATION FORM

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Rolf Rodgers
5 years ago
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1 PART A: APPLICATION FORM Please provide the following information regarding your child/youth. If you have previously submitted an application package and have not been offered a group, you do not need to re-submit an application package. If your child/youth is eligible for services, you will be contacted once a group appropriate for your child is arranged. Please note that space in a group is not guaranteed. Please drop off Application Package (including Application Form and Questionnaire) and documentation supporting your child/youth s ASD diagnosis to their school office or to Educational Services (164 Van Order Drive). For questions or additional information regarding the program please contact: Jessica Janssens, Coordinator of the Kingston After School ABA Program Phone: janssensj@limestone.on.ca Fax: CHILD/ YOUTH INFORMATION: Name of Child/ Youth: Date Package was Completed: Name of Person Completing Package: Gender: Date of Birth (mm/dd/yyyy): Grade: School Board (circle one): Algonquin and Lakeshore Catholic District School Board Limestone District School Board School Child/ Youth Attends: Name of Teacher: 1

2 Current supports in the school (i.e., EA, Autism Team, Student Services): Is the child/youth currently receiving group or individual services (private or public)? YES NO If so, what services are they receiving and from where? MEDICAL/ PSYCHOLOGICAL INFORMATION Is the child/youth on any medications? If yes, please specify. Yes: No Known Allergies: Please list all of the child/youth s diagnoses (including medical and psychological): *Please attach documentation confirming ASD diagnosis. PARENT/ CAREGIVER INFORMATION Name: _ Relationship to child/youth: _ Name: _ Relationship to child/youth: 2

3 Contact Information: Home: Cell: Work: Address: Address: Prefer to be reached by : Home Cell Work Contact Information: Home: Cell: Work: Address: Address: Prefer to be reached by : Home Cell Work Number of parents/caregivers that can attend weekly parent information sessions: Preferred Location for Group (region): GROUP INFORMATION East Central West Preferred Skills Group: Social/ Interpersonal (i.e., asking a friend to play, suggesting an activity) Communication (i.e., beginning a conversation, taking turns in a conversation) Behaviour/ Emotional Regulation (i.e., knowing and identifying feelings) Daily Living Skills (i.e., personal hygiene, laundry, transportation) School/Group Readiness (i.e., listening, turn taking, waiting) Child/youth s Communication: Single Words Short Phrases Full Sentences Non-Verbal Comments: Has the child/youth participated in a group setting in the past? If yes, please explain. Yes: No 3

4 PART B: QUESTIONNAIRE Please answer the following questions based on the child/youth s current skills. Please note that you only need to answer the questions that are applicable to your child/youth. Instructions: SKILL AREAS For each of the skills listed below, please indicate whether the child/youth never, seldom, sometimes, often or always uses the skill. This checklist will assist us in selecting the appropriate group and topics. Rating scale: 1= Child/youth never uses the skill 2= Child/youth seldom uses the skill 3= Child/youth sometimes uses the skill 4= Child/youth often uses the skill 5= Child/youth always uses the skill School/ Group Readiness Listening & Following Directions Responding to Joint Attention: Can the child look at an object that another person has directed their attention to? Initiating Joint Attention: Can the child point towards or look at an object, look to another person and then look back at the object of interest? Imitation: Can the child copy the actions of a peer or adult both spontaneously or when asked to? 4

5 Turn Taking: Can the child give up his/her turn? Waiting: Can the child wait for his/her turn? Communication Listening: Does the child/youth attend to someone who is talking? Beginning a Conversation Ending a Conversation Asking for Help Having a Conversation: i.e. join in a conversation by asking a question or making a comment Conversational Manners: i.e., please, thank you, you re welcome. Negotiating: Is the child/youth able to come up with a plan and compromise with another person? Taking Turns in a Conversation 5

6 Responding Appropriately During a Conversation: Is the child/youth able to ask questions/make comments during a conversation? Understanding Nonverbal Behaviour: Is the child/youth able to accurately recognize and interpret nonverbal cues? Understanding Tone of Voice Cues Public vs. Private: Is the child/youth able to identify private versus public settings? Behaviour/ Emotional Regulation Knowing their Feelings: Is the child/youth able to identify their internal emotions? Expressing their Feelings: Does the child/youth express his/her internal feelings/emotions? Using Relaxation/ Coping Strategies: Is the child/youth able to use a relaxation/ coping strategy when they are mad/sad? Dealing with Problems: Is the child/youth able to come up with a possible solution to a problem? Accepting no Redirecting Negative Thoughts: Does the child/youth reframe negative thoughts into positive thoughts? 6

7 Social/ Interpersonal Skills Introducing Him/Herself Joining In Inviting Someone to Play Playing a Game with Others Being a Good Sport: (i.e., they win appropriately, say good game to others etc.) Dealing with Losing Suggesting an Activity Sharing Apologizing to Others Responding Appropriately to Teasing 7

8 Giving a Compliment Accepting a Compliment Offering Help to Others Deciding What Caused a Problem Personal Safety and Boundaries Activities of Daily Living Grocery Shopping Meal Preparation Doing Dishes Laundry 8

9 Transportation: (i.e. taking public transit) Other Daily Living Skills Resume Writing Interview Skills Budgeting 9

Cambridge Public Schools SEL Benchmarks K-12

Cambridge Public Schools SEL Benchmarks K-12 OVERVIEW SEL Competencies Goal I: Develop selfawareness Goal II: Develop and Goal III: Develop social Goal IV: Demonstrate Goal V: Demonstrate skills to demonstrate