Dear Parent/Guardian: Thank you for your interest in the St.Amant Autism Programs. Please find enclosed is the application package for the St.Amant Autism Early Learning Program. Here are a few resources you may want to refer to in order to learn more about Applied Behaviour Analysis (ABA) and our program: St.Amant s website has an expanded ABA section at www.stamant.ca. It includes a short video about families in our program and several other interesting and useful links Upon receipt of your application, an individual from Central Intake will contact your family to ensure everything is complete. Manitoba Families for Effective Autism Treatment (MFEAT), the parent advocacy and networking group associated with the St.Amant Autism Programs can be reached at (204) 487-1685 or by email at www.mfeat.ca If you have further questions or would like to set up a time to meet about the Early Learning Program, please do not hesitate to contact Central Intake at (204) 256-4301 extension 7041. We welcome the opportunity to discuss our services with you.
Early Learning Program Application Form Date Received: Eligible: 0 Yes 0 No Ineligible Date: Intake Meeting: Start Date: CHILD INFORMATION Name: Birth date:* Male Female (First) (Middle) (Last) (Day/Month/Year) (Please Circle) Address: Phone #: (Street / City / Postal Code) Personal MB Health #: (9 digit number) School division in which the child belongs: * Please attach a photocopy of the child s birth certificate. LEGAL GUARDIANS Parents CFS Other Name: Address: Phone #: (Street / City / Postal Code) PRIMARY CAREGIVERS (When different than above) Name: Phone #: Address: (Street / City / Postal Code) FAMILY INFORMATION Father s Name: Home Address: Mother s Name: Home Address: Home Phone #: Home Phone #: Place of Work: Place of Work: Work Phone #: Work Phone #: Other Phone #: Other Phone #: Custodial Parent? Yes No Custodial Parent? Yes No Married Common-Law Separated Divorced Single Widowed In the case of joint custody, both parent signatures are required on Page 3. In the case of sole custody, documentation must be provided to show evidence of such arrangement. Only the custodial parent signature is required on Page 3. Are both custodial parents in agreement with the application? Yes No 1
ST.AMANT VALUES CULTURAL AWARENESS It is optional to provide the following information on your family: Cultural background: Primary language: Other languages spoken: LANGUAGE PREFERENCE In which of the two Canadian official languages would you prefer ABA services? English French MEDICAL INFORMATION Does anyone have allergies in your home? Yes No If yes, please list allergens: Please describe in detail any medication, vitamins, and/or special diet your child is currently receiving. If and when changes occur, the parent/legal guardian commits to immediately notify the St.Amant Autism Programs in writing. Upon Application Date: Intake Meeting Date: * DIAGNOSTIC INFORMATION Diagnosis: Name of professional who made the diagnosis: Address of professional who made the diagnosis: Date Diagnosed: (Day/Month/Year) Does your child have any other diagnosis or medical concerns? Yes No If yes, please explain: * Please attach the Verification of Diagnosis form. HOW DID YOU HEAR ABOUT THE ST.AMANT AUTISM PROGRAMS? Paediatrician Child Development Clinic Children s disability Services (e.g., Family Services Worker) Clinician (e.g., Occupational Therapist, Speech and Language Pathologist, Physiotherapist) Family/Friend St.Amant s website Media (e.g., radio, advertisements, news) Other: 2
CURRENT SERVICES Family Services Worker Name: Phone #: Does your child currently attend nursery school or day care? Yes No Attendance schedule: Nursery School/Day Care Name: Address: Phone #: (Street / City / Postal Code) Nursery School/Day Care Director Name: Please indicate the services your child is currently receiving: Type of Service Yes No Administrative Use Only ABA Therapy Occupational Therapy Physiotherapy Speech Therapy Child Development Counsellor HSC Autism Services Other (Please Specify) ST.AMANT AUTISM PROGRAMS AND AUTISM OUTREACH If I have applied to both St.Amant Autism Programs and Autism Outreach, I understand that once my child begins receiving full service from one of the provincially funded programs (this does NOT include participation in the St.Amant Parent Support Model), he/she is no longer eligible to remain on the waitlist for the other program. For example, should Autism Outreach offer services to my child first, I can proceed with Autism Outreach and my child s name would be removed from the waitlist for the St.Amant Autism Programs. I may also choose to decline the services offered by Autism Outreach at that time, and maintain a position on the St.Amant Autism Programs waitlist. In order to ensure that both programs manage their respective waiting lists effectively, St.Amant Autism Programs and Autism Outreach will share all information regarding a family s decisions regarding choice of service. I understand that St.Amant Autism Programs and Autism Outreach will share information regarding my child s status on each program s respective waitlists. Yes (initial) SIGNATURES Father Mother Legal Guardian s Relationship to Child (if not parent) Legal Guardian s Relationship to Child (if not parent) Date (Day/Month/Year) Date (Day/Month/Year) 3
ST.AMANT AUTISM PROGRAMS VERIFICATION OF DIAGNOSIS FORM To be completed by a qualified paediatrician, psychologist, or psychiatrist. Note: To be eligible for the St.Amant Autism Programs, a child must be diagnosed with Autism Spectrum Disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth Edition. CHILD INFORMATION Name: Birth date: Male Female (First) (Middle) (Last) (Day/Month/Year) (Please Circle) Address: Phone #: (Street / City / Postal Code) Manitoba Health Registration Number (6 digits): Personal Health Identification Number (9 digits): DIAGNOSTIC INFORMATION (Please Print) Eligible Diagnosis: Date of Diagnosis: Name of Diagnostician: Qualifications: Address: Phone number: Fax number: Signature: Today s Date: Administrative Use Only 4
Consent for Exchange of Information and Provision of Services NAME OF CHILD D.O.B. MANITOBA HEALTH # CONSENT FOR REFERRAL AND PROVISION OF SERVICES: I am in agreement with a referral for service and the provision of services through the St.Amant Autism Programs. CONSENT FOR EXCHANGE OF INFORMATION: Under Section 22(2)(a) of the Personal Health Information Act (PHIA) (legislation in the province of Manitoba) referring agencies and other related services may exchange information for the purpose of assessment, treatment and summary reports. Under Section 23(1)(a,b,c) of PHIA information may be exchanged with the immediate next of kin. Other person(s) not authorized under the Act who wish to receive information or a copy of a report are required to obtain written consent from the individual, their authorized legal representative, or their legal guardian. Please consider key individuals when providing consent for exchange of information or reports. For instance, physicians, case managers, private therapy providers, and other agencies such as SMD, RCC, Child Development Clinic, and Children s disability Services. In situations of abuse, neglect, court order, and/or immediate threat of harm to self or others, disclosure of such information is required by law. Please assist us by completing the information in full. The following are the list of individuals with whom I understand information will be exchanged: NAME TITLE AGENCY ADDRESS / POSTAL CODE PHONE NUMBER I understand that the information collected and exchanged will be used for the purposes of assessment, planning, developing programs and/or strategies that will benefit the child. I understand the risks and benefits of consenting or refusing to consent. Information or reports of statistical nature may be shared with the funder for accountability, funding or research purposes. The St.Amant Autism Programs Consent to Exchange Information and Provision of Services form must be updated on a yearly basis. The consenter is advised to provide updated information as changes occur. RELATIONSHIP OF SIGNING AUTHORITY Parent(s): Joint Custody Sole Custody In the case of joint custody, both parents signatures are required unless a signed Authorization to Represent form is on file. In the case of sole custody, documentation must be provided as evidence of such agreement. Only the signature of the parent with legal decision making power is required. Child and Family Services Other (Specify): Signature of Guardian/ Legal Representative Signature of Joint Representative (if applicable) Signature of Witness Date Date Date
Family Application Checklist This checklist is provided for your convenience. Please review the following list to ensure that your application is complete and accurate. Complete the St.Amant Autism Programs application form pages 1-3. Verification of Diagnosis Form (page 4) o St.Amant Central Intake will send the Verification of Diagnosis Form to the diagnostician to have this completed. If your family would like for Central Intake to do so, please provide your consent by filling in the contact information for the diagnostician on the Consent for Exchange of Information and Provision of Services (page 5) o If your family would prefer to contact the diagnostician directly to complete the Verification of Diagnosis form, please contact Central Intake to get a copy of the form without the SAMPLE watermark. Attach a photocopy of your child s birth certificate. Send the completed application form and required documents to: Central Intake St.Amant 440 chemin River Road Winnipeg, Manitoba R2M 3Z9 In the absence of any of the requirements listed above, the application is not complete. Upon receipt of your application, an individual from Central Intake will contact your family to ensure everything is complete. If you have any questions or concerns, please do not hesitate to contact Central Intake at (204) 256-4301 extension 7041.
Approach: The St.Amant Autism Programs work to implement teaching and intervention plans based on the principles of Applied Behaviour Analysis (ABA) with the goal of improving socially important behaviour. There are several decades of research to support the effectiveness of ABA and it is currently considered best-practice for autism intervention. Name: St.Amant Autism Programs Parent Support Model Eligibility: Prior to school entrance Diagnosis of Autism Spectrum Disorder (ASD) Reside in the Province of Manitoba On waitlist for the St.Amant Autism Early Learning Program Duration: Up to 1 year Intensity and scope: Consultative model of service where St.Amant Autism staff support families to target 2-3 skills using ABA strategies to teach children meaningful skills Location of services: For children residing in the City of Winnipeg, services occur at St.Amant located at 440 River Road For children residing outside the City of Winnipeg, services will occur in their home community or in close proximity St.Amant team members: Autism Consultant - assesses, plans, and designs individualized programming Autism Senior Tutor trains the parents how to implement programming developed by the Autism Consultant Parental involvement: A minimum of 10 hours per week of parent-led teaching Participation in required meetings Name: St.Amant Autism Early Learning Program (Comprehensive or Focused Model) Eligibility: Under the age of 5 upon entrance Diagnosis of Autism Spectrum Disorder (ASD) Reside in the Province of Manitoba Duration: Up to 3 years. Children are eligible to receive up to two years of Comprehensive or Focused services, plus up to one year of less intensive programming until the September of the year they turn 5. Intensity: Comprehensive model - 36 hours per week including 5 hours of parent-led teaching Focused model - 20.5 hours per week including 5 parent-led teaching hours Scope: The intensive, planned, and consistent application of ABA strategies to teach children meaningful skills in various areas, in both structured and natural environments Location of services: Homes, childcare facilities, preschools and/or nursery schools St.Amant team members: Autism Consultant - assesses, plans, and designs individualized programming; trains and supervises staff Autism Senior Tutor supervises and trains tutors and parents on programs developed by the Autism Consultant Autism Tutor - direct staff teaches the child on a daily basis Parental involvement: A minimum of 5 hours per week parent-led teaching Participation in required meetings
Name: St.Amant Autism School-Age Learning Program (Focused Model) Eligibility: Participated in the St.Amant Autism Early Learning Program or another intensive behavioural intervention outside the Province of Manitoba Duration: One year of a Focused model of service. Intensity: Focused model approximately 5 to 10 learning goals throughout the student s day, optional 5 hours of tutoring outside of school hours, 5 parent-led teaching hours Scope: The intensive, planned, and consistent application of ABA strategies to teach children meaningful skills in various areas Location of services: Private and public school, home Staff team members: Autism Consultant - assesses, plans, and designs individualized programming; trains school staff and parents Autism Senior Tutor supports school staff and parents on how to implement programming developed by the Autism Consultant Parental involvement: A minimum of 5 hours per week of parent-led teaching Participation in required meetings Name: St.Amant Autism School-Age Learning Program (Consultative Services) Currently under development School based referral services Based on student s needs Services available until high school graduation
References for Parents Book for parents on what is ABA? Applied Behavior Analysis and Autism: An Introduction by Suzanne M. Buchanan, Psy.D., BCBA & Mary Jane Weiss, Ph.D., BCBA Right from the Start Behavioral Intervention for Young Children with Autism by Sandra L. Harris, Ph.D. & Mary Jane Weiss, Ph.D. Understanding Applied Behavior Analysis: An Introduction to ABA for Parents, Teachers, and Other Professionals (JKP Essentials Series) by Albert J. Kearney Self-help manuals on how-to Behavior Modification: What It Is and How To Do It (9th Edition) by Garry Martin & Joseph Pear The Verbal Behavior Approach: How to Teach Children with Autism and Related Disorders by Mary Barbera Self-Help Skills for People with Autism: A Systematic Teaching Approach (Topics in Autism) by Stephen R. Anderson Textbook style for a thorough read on ABA: Applied Behavior Analysis (2nd Edition) by John O. Cooper Functional Behavioral Assessment, Diagnosis, and Treatment: A Complete System for Education and Mental Health Settings by Ennio Cipani Verbal Behavior Analysis: Inducing and Expanding New Verbal Capabilities in Children with Language Delays by R. Douglas Greer
References for Parents Websites (click on link) St.Amant s Learning Centre: www.stamant.ca/learning-centre Manitoba Families for Effective Autism Treatment: www.mfeat.ca Association for Science in Autism Treatment: www.asatonline.org Department of Health; New York State: www.health.state.ny.us/community/infants_children/early_intervention/disorders/autism Association for Behaviour Analysis International: www.autismsig.org Parent Professional Partnership - Association for Behaviour Analysis International: www.pppsig.org New Jersey Public Television & Radio: Decoding Autism Possible Causes, Cutting Edge Research, and Hope for the Future www.njn.net/television/specials/decodingautism/about/watchonline/ A Parent s Help Guide: Helping Children with Autism www.helpguide.org/mental/autism_help.htm