Young Adult Social Group Sussex/Kent County
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1 Young Adult Social Group Sussex/Kent County Autism Delaware is pleased to announce we are now accepting applications for our 2018 Young Adult Social Group! Here s the Who, What, Where, When: Dates: Starting 09/26/2018 this is an 8 Week Program offered on Wednesday Hours 6:00 PM to 7:30 PM (but this will depend on our activities) Location will vary, a calendar will be provided. Who: We have openings for Adults 19 through 30 with autism spectrum disorder Fee: $80 This is a drop off program and is considered Respite by DDDS. You MUST notify DDDS if you intend to utilize your respite find for this program. Contact the DDDS Respite Unit and/or Community Navigator to determine available funds for this program. In addition, a limited number of scholarships are available. Please contact Annalisa at annalisa.ekbladh@delautism.org or for more information and an application. Purpose of the Group: The Autism Delaware Young Adult Social Group is designed to provide a traditional social group experience with necessary supports from staff who understand the special needs of individuals with ASD. Our goal is to help each individual have a fun and successful recreation/social experience building new peer relationships, exploring new activities, and making gains in independence. Group will also provide the opportunity for respite for families! The social program is structured to be filled with new adventures within a repeating schedule. Activities may include: movies, restaurants, sporting events (maybe attending, an actual sport), AD s Amazing Race, maybe occasional travel, and more! Throughout each activity, emphasis is put on communication, social skills, and building self-esteem. We are basing the group on the PEERS Model, a nationally recognized curriculum developed by staff at the University of California. Please feel free to ask questions you may have about social group. Contact: Annalisa Ekbladh at or Annalisa.ekbladh@delautism.org.
2 Autism Delaware Young Adult Social Group Application Name of Participant: Birth date: / / Age: If Student is in school, What school program Address: City: State: Zip: Participant s Diagnosis: Autism Asperger s PDD-NOS Other: If you work, where do you work: If you are over 18, are you your own legal guardian? Yes No GROUP INFORMATION The following Young Adult Social Group policies will apply: Please keep in mind that part of group may involve being outdoors. Each potential participant is considered on a case by case basis. We cannot provide one on one staffing for any one participant. You know you re ready for group you have functional verbal communication and have an interest in being social. You should have an interest in participating in a group and group activities, and do not have frequent, intense aggressive behaviors. Participants may occasionally dine together. It is important to inform staff of any allergies/sensitivities you may have. Participants should also self-advocate should you have any allergies/food sensitivities.. Autism Delaware is not responsible for lost, broken, or stolen items. It is suggested to not bring electronics to events. We do not provide transportation to or from events. Families and/or individuals are responsible for providing their child s transportation. If you have transportation needs, we may be able to help connect families to set up car pools. Please let us know if you have any questions. We look forward to working with you and your family. Please send your completed application to Annalisa Ekbladh at Autism Delaware: Nassau Commons Blvd, Unit 1, Lewes, DE Or to Annalisa.ekbladh@delautism.org or fax to
3 CONTACT INFORMATION Autism Delaware Young Adult Social Group Parent/Guardian #1 Name: _If Applicable Home Phone: Work Phone: Cell Phone: (Please circle the best phone to reach you on while your child is at group) Address: City: State: Zip: Works at: City: ****************************************************************************************************************************************** Parent/Guardian #2 Name: If Applicable Home Phone: Work Phone: Cell Phone: (Please circle the best phone to reach you on while your child is at group) Address: City: State: Zip: Works at: City: ********************************************************************************************************************************************* If the above Parent/Guardians are not available in an emergency, notify: Emergency Contact Name: Home Phone: Work Phone: Cell Phone: Address City State Zip Works at: City: EDUCATIONAL Name of participant s school: State: Is the participant in a special autism educational program? Yes No Does this participant have an IEP? No Yes - If so, what is the participant s educational classification? Will you require 1:1 support in the following at any time? No Yes: If yes, why?
4 HEALTH INSURANCE INFORMATION Autism Delaware Young Adult Social Group Is the participant covered by family medical insurance? Yes No Health Insurance Company: Group #: Member #: *A photocopy of the front and back of camp participant health insurance card must be attached to this form. * PHYSICIAN INFORMATION Name of Participant s Physician: Phone: Address: Name of Participant s Dentist: Phone: Address: MEDICATIONS Please list ALL medications, including over-the-counter or nonprescription: This participant takes NO medications on a routine basis. This participant takes medications as follows: Med #1 Dosage: Reason: Specific times taken each day Prescribing Physician: Med #2 Dosage: Reason: Specific times taken each day Prescribing Physician: (Attach additional pages for more medications.) ALLERGIES (List all known. Also describe reaction and management of the reaction.) NO ALLERGIES Medication allergies (list): Food allergies (list): Other allergies (list): include insect stings, animal dander, etc.: RESTRICTIONS (attach additional pages if necessary) Participant does not eat: Red meat Pork Dairy products Poultry Seafood Eggs N/A-no restrictions Other (describe): Due to special diet, we will send/ bring in snacks/edible reinforcers for our child Explain any restrictions to activity
5 Autism Delaware Young Adult Social Group GENERAL MEDICAL HISTORY Are you currently healthy? Current medical conditions: Has/do you: YES NO 1 Ever had/have seizures? 2 Any recent injury, illness or infectious disease? 3 Chronic or recurring illness/condition? 4 Wear glasses, contacts or protective eye wear? 5 Persistent medical history/event in the past month? 6 Frequent headaches? 7 Ever had a head injury? 8 Ever had frequent ear infections? 9 Ever been knocked unconscious? 10 Ever had surgery? 11 Ever been hospitalized? 12 Ever passed out during or after exercise 13 Ever been dizzy during or after exercise? 14 Ever had chest pain during or after exercise? 15 Ever had high blood pressure? 16 Ever been diagnosed with a heart murmur? 17 Ever had back problems? 18 Ever had problems with joints (e.g., knees, ankles)? 19 Any skin problems (e.g., itching, rash, acne)? 20 Have diabetes? 21 Have asthma? Explain any yes answers, noting the number of the question first: Have you had the following : (Circle to indicate Yes ) Measles Chicken pox German measles Mumps Hepatitis A Hepatitis B Hepatitis C TB Mantoux test (Date of last test ) Result: Positive Negative
6 Autism Delaware Young Adult Social Group COMMUNICATION How communicate to ask for things, ask for help, indicate yes/no, etc.? MODE SPEAKS CLEARLY SPEAKS but MAY BE DIFFICULT TO UNDERSTAND PECS / PICTURES SIGN LANGUAGE COMMUNCIATION BOARD OR DEVICE GESTURES OTHER: PLEASE LIST EXAMPLES Language spoken/understood: Vision: Normal Mild/Moderate Loss Severe/Total Loss Wears corrective lenses Hearing: Normal Mild/Moderate Loss Severe/Total Loss Wears hearing aides Mobility Walks independently Walks with assistance: Uses wheelchair : manual power SELF-CARE Skill Independent- No assistance needed With Prompting Only With Supervision With Assistance Using Toilet Comments Undress Get dressed Wash hands Eat lunch SWIM EXPERIENCE Familiarity with pool/beach: Level of swimming skill: None- has not been in a pool or ocean/ beach Cannot swim at all, not comfortable in water Minimal experience with water at pool/beach Cannot swim but is comfortable in pool/beach. Likes the water Has spent some time at either pool or beach Can swim a little. Should not go in deep end. Has spent a lot of time in pool/beach, very comfortable Good swimmer. Can support self in water
7 Autism Delaware Young Adult Social Group Is there anything else you feel is important for us to know about the participant s medical history, health, communication, or self-care skills? Please note: behavior will be addressed below. BEHAVIOR Check any item(s) identifying behavior exhibited: Self-injury: Bites Hits/kicks Pulls hair Picks self Other: Aggression towards others: Bites Hits/kicks Pulls hair Other: Date of most recent aggressive behavior: Excessive cursing/vulgarity Temper tantrums Elevated emotional needs Overly dependent on others Seeks steady entertainment Wanders/runs from group Cries or becomes upset easily Exaggerates pain/illness Difficulty taking direction Seeks steady attention Screams Overly fearful Teases others Elevated sexual interest Other: List details to help explain behavior areas checked above and any specific methods to resolve behavior difficulties: Does this participant currently have a behavior support plan? Yes (If yes, Please send a copy) No Triggers: What makes you, angry, anxious, and/or overwhelmed? Being touched Loud Noises Yelling Having to rush/hurry Encroachment of personal space Bright or flashing lights Specific people or peers Introduction to new foods New places or schedules Crowds Heat/hot outside Not being able to finish something before moving on Other:
8 Autism Delaware Young Adult Social Group BEHAVIOR CONTINUED List any circumstances that will increase the likelihood of negative behavior (i.e. loud noises, animals, the dark, etc.). List situation and behavior displayed. Warning Signs: What are some warning signs that you exhibit when frustrated or in distress? Pacing Crying Yelling Sweating Clenching teeth Face turns red Not talking Swearing Running Clenching fists Breathing hard/fast Excessive or fast pace talking Being rude Not eating Throwing objects Verbal Comments: Other: Explain: Calming Strategies: What helps you calm down? Taking a walk Getting a drink of water Listening to music Reading a book Wrapping in a blanket Dark room (dim the lights) Stuffed animals Calling family member Taking a break/removal from environment until calm Talking to staff Writing/drawing Other: Explain: Are there key actions, words, or phrases used to stop behavior and redirect? No Yes - If yes, please explain: Please list any reinforcers you like, or things you will work for. **Keep in mind electronics are discouraged at social group** Although we do not provide direct instruction or implement specific behavior plans at social group, please share any specific things is currently working on that you would like us to encourage if possible. (Ex: talking to peers, asking for a break when overwhelmed, etc)
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