St.Amant Autism Programs 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). Please ensure that you have a witness sign on 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.
St.Amant Autism Programs Early Learning Program Application Form Date Received: Eligible: Yes 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, Children s disability Services (CdS), 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
St.Amant Autism Programs 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. Signature of Parent/Guardian 1 Legal Representative Signature of Parent/Guardian 2 Legal Representative Date Date Child and Family Services Other (Specify): Signature of Witness (Third party over the age of 18) Date
St.Amant Autism Programs 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
St.Amant Autism Programs 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
St.Amant Autism Early Learning Program The St.Amant Early Learning Program offers Early Intensive Behavioural Intervention (EIBI) to preschool children diagnosed with autism spectrum disorder (ASD). Two service models are available to families a Comprehensive model and a Focused model. Children are eligible to receive up to two years of Comprehensive or Focused services, plus up to one year of transitional programming until the September of the year they turn 5. The Comprehensive Model includes 36 hours of one-on-one home-based teaching sessions, five of which are parent-led. The program consists of individualized, structured and consistent application of Applied Behaviour Analysis strategies to teach children meaningful skills in areas such as communication, play, social interactions, daily living, pre-academic, academic and motor. The Focused Model provides 20 hours per week of one-to-one teaching, five of which are parent-led. In this model, fewer teaching goals are selected than in the Comprehensive model, but the intensity of programs remains the same. Goals are prioritized based on clinical assessments and parental input. Group settings such as early childhood education centers, nursery schools and community programs are included when deemed clinically appropriate and parents are encouraged to contact the Autism Programs to discuss alternatives to home-based models if necessary. Parents and guardians are valued members of the Early Learning Program team and we invest in their training and full participation, through monthly* Clinic Meetings and Parent Overlaps. * City, rural, and distance models vary in face-to-face hours. Early Learning Program Activities and Characteristics The Early Learning Program works collaboratively with our clients families and caregivers to provide sound, effective, evidence-supported educational programs. Programming is individualized and based on comprehensive assessments of each child. Assessments Children are assessed on several measures upon intake and yearly thereafter. Results are used to assess progress and determine learning goals. One-to-one teaching sessions Children receive two teaching sessions every day, five days a week. Each session is 3-3.5 hours long.
Clinic meetings Meetings are led by Autism Consultant every 1 to 3 months depending on the child's place of residence (e.g., Winnipeg, Northern Manitoba). All team members participate to discuss programming, successes and challenges. All team members work with the child and observe one another to achieve consistency for optimal learning. Overlaps The Autism Senior Tutor provides training and supervision sessions to Autism Tutors and parents every 2-4 weeks in the city of Winnipeg. Challenging behaviour support Autism Consultants prioritize improvement in challenging behaviour by using functional behavioural assessment / functional analysis to assess the causes and design Behavioural Intervention Plans that address those functions. Functional Communication Training is often used to improve communication to replace challenging behaviours. Promoting parental involvement Families are an integral part of their children's education and have a significant role in supporting the program. Parents have a commitment to provide five hours of programming to their children and participate in Clinic Meetings. Successful partnerships between professionals and parents contribute to better child learning outcomes. Teaching Programs / Lesson Plans Autism Consultants design teaching programs using strategies such as discrete-trials teaching (DTT), incidental teaching, chaining, prompting, fading. The Autism Consultants and Senior Tutors continuously monitor implementation of the teaching programs to ensure fidelity as continuous progress. They ensure child's progress is demonstrated through the summary of data. For more information, contact Central Intake at (204) 256-4301 extension 7041
St.Amant Autism School-Age Learning Program The St.Amant Autism School-Age Learning Program offers behavioural intervention for children diagnosed with Autism Spectrum Disorder (ASD) who have participated in the St.Amant Early Learning Program. Children are eligible to receive support from an Autism Consultant and Autism Senior Tutor in their school for up to one year. The goal of this service is to collaborate with school teams during the child s transition from early learning to school-based supports. In addition to collaborating with the school team to provide behavioural programming during school experiences, support is also provided at home (five hours of parent-led interventions and five hours of home-based tutor sessions are expected to supplement school programming). In the school, the Autism Consultant works in collaboration with the school team to incorporate learning principles to teach skills selected through the individual education plan (IEP) process. The IEP serves as a focal point of the child s educational planning and establishes meaningful goals that are agreed upon by the school staff team members, parents/guardians, and the Autism Consultant. Once the IEP is established, the Autism Consultant provides support by: Working with the school team to design programming around the goals he/she was assigned responsibility for in the IEP. Working with the school team to design feasible data collection systems to track student progress. Providing regular training on the implementation of behavioural strategies to team members who are facilitating one-to-one teaching with the student. Participating in additional school team meetings and providing updates on assigned IEP goals. In the home, the Autism Consultant develops programming to target skill acquisition in areas such as communication, socialization as well as increasing independence in daily living skills. In addition, if challenging behaviours are present, the Autism Consultant will support the home team by providing assessment tools, helpful behavioural strategies and behaviour plans as needed. Programming for the home environment is developed in collaboration with the child s parents. In both the home and school settings St.Amant also provides support from an Autism Senior Tutor. Support from the Autism Senior Tutor can include staff training, data collection training, data entry and summary. The activities of the Senior Tutor can vary depending on the goals and programming focus for each child. Overall the Autism Senior Tutor serves as a support to the entire team during and between their regular visits. For more information, contact Caroline Simard at (204) 256-4301, extension 3430.