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Your Name *
Your answer
Your Child's Name *
Your answer
When was your child diagnosed with Autism Spectrum Disorder *
Your answer
How would you describe your child's diagnosis
Phone Number *
Your answer
Mailing Address *
Your answer
Email *
Your answer
Child's Gender *
Child's Date of Birth *
Your answer
Relationship (to the child) *
Adult Participants' Name(s) *Please note that any and all adults who interact with your child are welcome including extended family members, friends, therapists, teachers, caregivers, etc. Feel free to list them below or invite them after our orientation session. *
Your answer
Adults in the Household *
Total People in the household *
List (name & age) the children in your household.
Your answer
Household Income *
BIANCA reAACts Session Availability. *NOTE: we cannot guarantee availability, please check all sessions you are able to attend. *
Session Preference: Please rank the sessions in order of preference *
Your answer
Does your child currently use an iPad as his/her AAC device? *
If YES, who supplied the iPad, (check all that apply) *
Check all apps that you have tried with your child *
Are you interested in changing your child's communication system *
Please briefly describe any financial, therapeutic, and emotional needs driving your participation in this program. *
Your answer
Does your child currently receive private speech-language therapy? *
Describe HOW your child communicates *
Inconsistent/ Almost Never
With prompting
Often/ Independently
uses PECS or picture icons
uses signs/ gestures (pointing, hand leading)
verbalizes single words
verbalizes short phrases
verbalizes conversationally
Describe WHY your child communicates. NOTE: Please choose the communication tool your child uses MOST OFTEN and with the LEAST amount of support. *
Can not tell me consistently or only I understand
Gestures (pointing, hand leading)
PECS/Picture Icons
AAC or Speech Generating Device
Verbalizes single words
Verbalizes short phrases
Verbalizes sentences/ conversations
Uses an AAC Device
To let me know what he/she needs
To ask for help
To let me know what he/she wants
To interact with me (sing songs, games)
To talk about his/her environment
To let me know how he/she feels (excited, does not like it)
Please tell us how you think this program will benefit you and your child. *
Your answer
Please describe what you hope to gain from this program. *
Your answer
Describe why you think this program is appropriate for you and your child. *
Your answer
Is there anything else you think we should know? *
Your answer
As a part of this program I will be participating in video tapped sessions including but not limited to video-tapped therapy session, still photos, and/or parent testimonials. BIANCA and The Crimson Treatment and Research Center will have the right to use these videos, photographs, and other non-identifying information (e.g. for education, promotion, etc.) for this and future projects. *
I do not agree to the above stipulation. Please describe what you are comfortable participating in.
Your answer
Signed *
Your answer
Date *
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