Spectrum Insights New Student Form- ASD Youth ages 12 - Adult
Name of Student *
Please note: Our programs are best suited to students diagnosed as level 1/Tier 1 Autism also known as Aspergers. Students should be able to have reciprocal conversations, take direction, handle transitions and sensory stimuli (oc transpo, busy streets, malls, movie theaters, walking, hot summer days). Students are also able to self regulate. *
After the form is completed we will arrange a time to meet you and your child/client for a short interview. Normally we prefer to meet in person. I like to keep it casual and stick to coffee shops, this way we can make observations in a public setting. During covid 19 restrictions, we may ask to meet via a Zoom meeting. Since Zoom is a pale replacement for an in person meeting. We are unable to observe your child at the cash, communicating w/ cashier, handling external stimuli, have a reciprocal conversation. We require parents to be as upfront as possible about their child's needs and take a good assessment if our programs will be suitable. We want your child to thrive in a program that best suits them. If a focus on social and life skills is the stage where your child needs support at this time and they want to connect w/ other social Tier one students, we would love to meet and discuss goals!
Clear selection
Age *
What programs are you interested in? *
Any Allergies *
Are there Medical concerns we should be aware of (ie: epilepsy, Prader Willie Syndrome etc) *
Are there Behavior Issues that we should be aware of? ( behaviors that would take staffs attention from the group for an extended period of time, cause physical or emotional harm to others or outbursts that threaten the safety of students/staff) *
Is he/she able to function independently in a group setting, 5-20 students (does not need one to one care). *
Mild sensory issues that may affect your child’s/clients day : ie light or sound
Goals for your child/client
Please note our coaching and groups are not appropriate for any aggressive behaviors, verbal bullying or students that may potentially run off. Students must be able to exhibit independence and ability to follow a sequence of instructions. Our social groups and summer camps are not suitable for students who need a lot of structure. Behavior should not take take a leader from the group for an extended period of time. Students need to be willing to take direction, wait for further clarification if needed and not argue in the moment. Students not able to follow the above will be asked to leave the program. Our space is safe and inclusive, students attend knowing they will be respected by their peers and staff confident they can care for the group. Our focus is on teaching social and life skills, not behavior management. *
Please provide your name and email (phone messages are so 90's) *
Thank you for your time, we will reply back soon to arrange a time to meet.
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