Clinical/Social Group Application - Ages 12-15
Please complete this form in order to apply for the upcoming Social Group for children aged 12-15 years old with Autism Spectrum Disorder. Our plan is to host the group on Saturdays in November and December (2022) at the KaleidAScope, Inc. Office (4934 Peach Street; Erie, PA 16509). 
Groups will be "in person."
*NOTE - Completing this application form DOES NOT guarantee your child a spot in the social group. You will be contacted by KAS staff to move forward in the process. If you have any questions, please contact our office at (814) 824-4515.*
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First and Last Name of the individual who will be participating in the social group. *
Date of Birth of the individual who will be participating in the social group. (NOTE - This group is targeted for children aged 12-15 years old) *
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Has the individual who will be participating in the social group been diagnosed with Autism? *
Has the individual who will be participating in group ever participated in a clinical social group before? *
Has the person who will be participating in the group ever received (or are they currently receiving) any kind of clinical or educational support or services related to their ASD diagnoses? *
If you answered "yes" to the previous question, please describe (example: Lucy has an IEP and goes to Dr. Jane for therapy).
What do you hope that the person who will be participating in the group accomplishes or learns through participation? *
How does the person who will be participating in the group feel about being a part of this group? (example: reluctant, but willing; very excited; not sure if she wants to attend but I think it's a good idea) *
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