Nicholas Center's Application of Interest
Please fill out the Application of Interest below, so we can learn a bit more about you, and your needs. If we feel we can accommodate your requests, we will be in touch shortly! Thank you so much.

THIS DOES NOT GUARANTEE PLACEMENT

THIS WILL PLACE YOU ON OUR WAITING LIST.

A "* " DENOTES MANDATORY FIELD. FORM WILL NOT SUBMIT WITHOUT AN ANSWER.
Email address *
Today's Date *
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Location of Interest *
Required
Name of the Applicant *
Current Age *
Gender *
Required
Name of person filling out the form, if not "applicant" *
Relationship to applicant *
Contact Number *
Street Address *
City, State , Zipcode *
How did you hear about The Nicholas Center? *
What is the primary diagnoses of the applicant? (Note we primarily serve those on the Autism Spectrum) *
Which services are you interested in? Check all that apply *
Required
How are services being funded? *
Required
Frequency Per week *
Required
School/Program attended(ing) *
Can the applicant work in a community setting, safely and productively, within a small group (if No, Please explain) *
Can the applicant tolerate a mask and socially distance independently? Yes or No *
Required
Please list atleast 3 preferred activities, items or interests *
Does the applicant require 1:1 support for any behavioral, mobility or medical needs? If yes, please explain *
Does the applicant currently have a 1:1? *
Does the applicant engage in any challenging behaviors (ex. outbursts, aggression) If so, under what circumstances would it occur *
Are there any specific trigger phrases, words, fears, anxieties that we should be aware of? *
What methods are used to alleviate any anxieties , frustrations or fears *
Does the applicant have an educational or behavioral consultant. If so, please name below *
Does the applicant have any history of wandering or elopement or running away? *
Are there any special accomodations or needs we should be made aware of? *
Please describe the applicant's ability to communicate their needs (please describe) *
Explain any and all work related experiences (Paid, volunteer, location, duties etc.) *
Does the applicant have reliable and timely transportation? Yes or No. If No, are they able to wait independently without supervision? *
Can the applicant safely navigate within a familiar community, independently and without supervision? *
Please add any other comments you would like us to know about the applicant:
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