Tell us about your child

Your child's first and last name?

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* 1. Your child's first and last name?

Which age group are you interested in for this summer?

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* 2. Which age group are you interested in for this summer?

For how many weeks do you want to attend? If less than 6 weeks, please indicate which dates will be missed?

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* 3. For how many weeks do you want to attend? If less than 6 weeks, please indicate which dates will be missed?

Demographics

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* 4. Demographics

What is his/her diagnosis?

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* 5. What is his/her diagnosis?

Does your child want to attend BADP? If so, please explain why? If not, please also explain why? This will better prepare us for the intake.

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* 6. Does your child want to attend BADP? If so, please explain why? If not, please also explain why? This will better prepare us for the intake.

Please describe in detail his/her social difficulties in structured settings, such as the classroom, organized sports, etc...?

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* 7. Please describe in detail his/her social difficulties in structured settings, such as the classroom, organized sports, etc...?

Please describe in detail his/her social difficulties in unstructured settings, such as gym, recess, play-dates, birthday parties, after-school activities, etc...

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* 8. Please describe in detail his/her social difficulties in unstructured settings, such as gym, recess, play-dates, birthday parties, after-school activities, etc...

What are the typical triggers that make your child upset?

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* 9. What are the typical triggers that make your child upset?

What is an effective way to intervene when your child becomes upset?

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* 10. What is an effective way to intervene when your child becomes upset?

Do you use time-outs? If so, how easily does your child take a time-out? Is there every any resistance? If so, why kind of resistance? Please be specific.

If you don't use time-outs, why not? What do you do instead when he/she is non-compliant, breaking rules or acting unsafe? Please be specific.

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* 11. Do you use time-outs? If so, how easily does your child take a time-out? Is there every any resistance? If so, why kind of resistance? Please be specific.

If you don't use time-outs, why not? What do you do instead when he/she is non-compliant, breaking rules or acting unsafe? Please be specific.

What group activities does your child do after school or on the weekends? sports, gymnastics, robotics, etc. Are there any specific social issues you notice?

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* 12. What group activities does your child do after school or on the weekends? sports, gymnastics, robotics, etc. Are there any specific social issues you notice?

What services is your child currently receiving outside of school?

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* 13. What services is your child currently receiving outside of school?

Describe his/her academic difficulties that you want him/her to improve over the summer?

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* 14. Describe his/her academic difficulties that you want him/her to improve over the summer?

Briefly describe his/her strengths?

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* 15. Briefly describe his/her strengths?

What incentives, if any, motivate your child (e.g., charts, points, toys, money, food, TV, video games, etc...)

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* 16. What incentives, if any, motivate your child (e.g., charts, points, toys, money, food, TV, video games, etc...)

What did your child do last summer? Did he/she attend camp? Please describe any notable issues that would help us for this summer?

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* 17. What did your child do last summer? Did he/she attend camp? Please describe any notable issues that would help us for this summer?

Any current or recent (in past 6 months) history of aggression to kids (peers, siblings, etc..) or adults (parents, teachers, etc...), running away or destruction of property?

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* 18. Any current or recent (in past 6 months) history of aggression to kids (peers, siblings, etc..) or adults (parents, teachers, etc...), running away or destruction of property?

Any current or history of sexual abuse or trauma with your child or in the family?

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* 19. Any current or history of sexual abuse or trauma with your child or in the family?

Does your child have any self-care issues (e.g., toileting, changing clothes, etc...)

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* 20. Does your child have any self-care issues (e.g., toileting, changing clothes, etc...)

Does your child have any medical or physical problems? Allergies? Food issues? Major dietary restrictions?

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* 21. Does your child have any medical or physical problems? Allergies? Food issues? Major dietary restrictions?

Does he/she take medication? If yes, please describe with names of medications and reason for taking the medication.

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* 22. Does he/she take medication? If yes, please describe with names of medications and reason for taking the medication.

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