ASRC Program Participant Needs Assessment

This form is required for all ASRC program participants. Please complete the form in its entirety, answering each question to the best of your ability.

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* 1. ASD as primary diagnosis is required. Applications will not be considered until proper diagnosis is received. Email diagnosis document to asggc@yahoo.com. Please confirm acknowledgement of this policy.

Yes

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* 2. Participant Full Name

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* 3. Participant DOB

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* 4. Participant Age

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* 5. Medical Needs/Concerns/Diagnoses. If none, answer "none".

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* 6. Assistance
** For those requiring one on one assistance, a parent/guardian may be needed to provide assistance to participant

The participant requires one on one assistance with most daily activities **

The participant requires frequent prompts/redirection to remain on task

The participant requires minimal prompts/redirection to remain on task

Please explain in further detail.

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* 7. Communication

Verbal - Is able to communicate independently, understand, follow and repeat directions, hold reciprocal conversations, and state needs without assistance

Limited verbal - Is able to communicate needs/wants with some assistance, communicates in one to two sentences,

Non-verbal - Is unable to communicate verbally

Please explain the participants communication in further detail.

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* 8. Is participant prone to wandering/running/eloping/leaving the area without permission?

Yes

Please elaborate

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* 9. Is participant independent in toileting and associated use of facilities? (button/zip pants, wipe, recognize need to use the restroom and seek assistance locating it).

Yes

Please elaborate

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* 10. Fine Motor

	Never	Sometimes or Partially	Usually or Always
Holds a pen, pencil, or paintbrush appropriately	Holds a pen, pencil, or paintbrush appropriately Never	Holds a pen, pencil, or paintbrush appropriately Sometimes or Partially	Holds a pen, pencil, or paintbrush appropriately Usually or Always
Cuts out simple shapes	Cuts out simple shapes Never	Cuts out simple shapes Sometimes or Partially	Cuts out simple shapes Usually or Always
Ties shoes securely	Ties shoes securely Never	Ties shoes securely Sometimes or Partially	Ties shoes securely Usually or Always
Zips, fastens, buttons clothes when changing or using the restroom	Zips, fastens, buttons clothes when changing or using the restroom Never	Zips, fastens, buttons clothes when changing or using the restroom Sometimes or Partially	Zips, fastens, buttons clothes when changing or using the restroom Usually or Always

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* 11. Gross Motor

	Never	Sometimes or Partially	Usually or Always
Runs smoothly without falling	Runs smoothly without falling Never	Runs smoothly without falling Sometimes or Partially	Runs smoothly without falling Usually or Always
Climbs on and off high objects (playground equipment)	Climbs on and off high objects (playground equipment) Never	Climbs on and off high objects (playground equipment) Sometimes or Partially	Climbs on and off high objects (playground equipment) Usually or Always
Catches a tennis or baseball-sized ball, moving to the ball as necessary	Catches a tennis or baseball-sized ball, moving to the ball as necessary Never	Catches a tennis or baseball-sized ball, moving to the ball as necessary Sometimes or Partially	Catches a tennis or baseball-sized ball, moving to the ball as necessary Usually or Always

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* 12. Self Care

	Never	Sometimes or Partially	Usually or Always
Is toilet-trained and will tell an adult when they need to use the restroom	Is toilet-trained and will tell an adult when they need to use the restroom Never	Is toilet-trained and will tell an adult when they need to use the restroom Sometimes or Partially	Is toilet-trained and will tell an adult when they need to use the restroom Usually or Always
Cleans or wipes hands and face during or after meals without prompting	Cleans or wipes hands and face during or after meals without prompting Never	Cleans or wipes hands and face during or after meals without prompting Sometimes or Partially	Cleans or wipes hands and face during or after meals without prompting Usually or Always
Requires assistance using the restroom (unbuttoning pants, wiping, pulling pants up)	Requires assistance using the restroom (unbuttoning pants, wiping, pulling pants up) Never	Requires assistance using the restroom (unbuttoning pants, wiping, pulling pants up) Sometimes or Partially	Requires assistance using the restroom (unbuttoning pants, wiping, pulling pants up) Usually or Always
Seeks assistance when needed (injury, illness, pain or discomfort)	Seeks assistance when needed (injury, illness, pain or discomfort) Never	Seeks assistance when needed (injury, illness, pain or discomfort) Sometimes or Partially	Seeks assistance when needed (injury, illness, pain or discomfort) Usually or Always
Follows directions for a special diet or takes medications independently (if applicable)	Follows directions for a special diet or takes medications independently (if applicable) Never	Follows directions for a special diet or takes medications independently (if applicable) Sometimes or Partially	Follows directions for a special diet or takes medications independently (if applicable) Usually or Always
Has eating difficulties (eats too fast, too slow, overeats or refuses to eat)	Has eating difficulties (eats too fast, too slow, overeats or refuses to eat) Never	Has eating difficulties (eats too fast, too slow, overeats or refuses to eat) Sometimes or Partially	Has eating difficulties (eats too fast, too slow, overeats or refuses to eat) Usually or Always

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* 13. Communication

	Never	Sometimes or Partially	Usually or Always
Says at least 100 recognizable words	Says at least 100 recognizable words Never	Says at least 100 recognizable words Sometimes or Partially	Says at least 100 recognizable words Usually or Always
Uses mostly gestures to communicate	Uses mostly gestures to communicate Never	Uses mostly gestures to communicate Sometimes or Partially	Uses mostly gestures to communicate Usually or Always
Pronounces words clearly	Pronounces words clearly Never	Pronounces words clearly Sometimes or Partially	Pronounces words clearly Usually or Always
Tells about an experience in detail (who was involved, what happened, where it took place)	Tells about an experience in detail (who was involved, what happened, where it took place) Never	Tells about an experience in detail (who was involved, what happened, where it took place) Sometimes or Partially	Tells about an experience in detail (who was involved, what happened, where it took place) Usually or Always

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* 14. Comprehension

	Never	Sometimes or Partially	Usually or Always
Listens to and understands spoken instructions	Listens to and understands spoken instructions Never	Listens to and understands spoken instructions Sometimes or Partially	Listens to and understands spoken instructions Usually or Always
Follows instructions in "if-then" form ("if you want to play the game, then put away your toys")	Follows instructions in "if-then" form ("if you want to play the game, then put away your toys") Never	Follows instructions in "if-then" form ("if you want to play the game, then put away your toys") Sometimes or Partially	Follows instructions in "if-then" form ("if you want to play the game, then put away your toys") Usually or Always
Listens to a story for at least 15 minutes	Listens to a story for at least 15 minutes Never	Listens to a story for at least 15 minutes Sometimes or Partially	Listens to a story for at least 15 minutes Usually or Always
Follows directions or instructions heard 5 minutes before	Follows directions or instructions heard 5 minutes before Never	Follows directions or instructions heard 5 minutes before Sometimes or Partially	Follows directions or instructions heard 5 minutes before Usually or Always
Uses and/or understands visual schedules	Uses and/or understands visual schedules Never	Uses and/or understands visual schedules Sometimes or Partially	Uses and/or understands visual schedules Usually or Always
Benefits from having pictures available to understand directions	Benefits from having pictures available to understand directions Never	Benefits from having pictures available to understand directions Sometimes or Partially	Benefits from having pictures available to understand directions Usually or Always

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* 15. Behavior

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* 16. Relating to Others

	Never	Sometimes or Partially	Usually or Always
Makes or tries to make social contact	Makes or tries to make social contact Never	Makes or tries to make social contact Sometimes or Partially	Makes or tries to make social contact Usually or Always
Recognizes the likes and dislikes of others	Recognizes the likes and dislikes of others Never	Recognizes the likes and dislikes of others Sometimes or Partially	Recognizes the likes and dislikes of others Usually or Always
Keeps comfortable distance between self and others in social situations	Keeps comfortable distance between self and others in social situations Never	Keeps comfortable distance between self and others in social situations Sometimes or Partially	Keeps comfortable distance between self and others in social situations Usually or Always
Avoids rude or embarrassing comments/behaviors in public	Avoids rude or embarrassing comments/behaviors in public Never	Avoids rude or embarrassing comments/behaviors in public Sometimes or Partially	Avoids rude or embarrassing comments/behaviors in public Usually or Always
Plays successfully with one of more children for more than 5 minutes	Plays successfully with one of more children for more than 5 minutes Never	Plays successfully with one of more children for more than 5 minutes Sometimes or Partially	Plays successfully with one of more children for more than 5 minutes Usually or Always
Shows good sportsmanship, follows the rules of the game, does not get mad when losing a game	Shows good sportsmanship, follows the rules of the game, does not get mad when losing a game Never	Shows good sportsmanship, follows the rules of the game, does not get mad when losing a game Sometimes or Partially	Shows good sportsmanship, follows the rules of the game, does not get mad when losing a game Usually or Always
Does not become overly aggressive when playing a sport/game	Does not become overly aggressive when playing a sport/game Never	Does not become overly aggressive when playing a sport/game Sometimes or Partially	Does not become overly aggressive when playing a sport/game Usually or Always
Responds appropriately to slight changes in routine	Responds appropriately to slight changes in routine Never	Responds appropriately to slight changes in routine Sometimes or Partially	Responds appropriately to slight changes in routine Usually or Always
Chooses not to taunt, tease or bully peers	Chooses not to taunt, tease or bully peers Never	Chooses not to taunt, tease or bully peers Sometimes or Partially	Chooses not to taunt, tease or bully peers Usually or Always
Displays empathy for peers who are having a difficult time	Displays empathy for peers who are having a difficult time Never	Displays empathy for peers who are having a difficult time Sometimes or Partially	Displays empathy for peers who are having a difficult time Usually or Always
Avoids others and prefers to be alone	Avoids others and prefers to be alone Never	Avoids others and prefers to be alone Sometimes or Partially	Avoids others and prefers to be alone Usually or Always
Is overly dependent on parent/caregiver/teacher	Is overly dependent on parent/caregiver/teacher Never	Is overly dependent on parent/caregiver/teacher Sometimes or Partially	Is overly dependent on parent/caregiver/teacher Usually or Always

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* 17. List anything that motivates the participant.

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* 18. What type of educational program is the participant currently enrolled? If enrolled in a program, what support do they receive?

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* 19. Below, please share with us any and all additional information about the participant that would assist us in making this experience successful for them. Examples include but are not limited to: Supports you feel the participant would need. Triggers. Behavioral concerns. Sensory sensitivities. Means of de-escalation.

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* 20. Contact information for person completing the form

Name

Relationship to participant

Email Address

Phone Number

	Never	Sometimes or Partially	Usually or Always
Understand dangerous/risky situations	Understand dangerous/risky situations Never	Understand dangerous/risky situations Sometimes or Partially	Understand dangerous/risky situations Usually or Always
Chooses to avoid/is fearful of dangerous/risky situations	Chooses to avoid/is fearful of dangerous/risky situations Never	Chooses to avoid/is fearful of dangerous/risky situations Sometimes or Partially	Chooses to avoid/is fearful of dangerous/risky situations Usually or Always
Controls anger when he/she does not get his or her own way	Controls anger when he/she does not get his or her own way Never	Controls anger when he/she does not get his or her own way Sometimes or Partially	Controls anger when he/she does not get his or her own way Usually or Always
Gets anxious or nervous easily	Gets anxious or nervous easily Never	Gets anxious or nervous easily Sometimes or Partially	Gets anxious or nervous easily Usually or Always
Is impulsive	Is impulsive Never	Is impulsive Sometimes or Partially	Is impulsive Usually or Always
Wanders or runs away	Wanders or runs away Never	Wanders or runs away Sometimes or Partially	Wanders or runs away Usually or Always
Has meltdowns in the home/school/community setting	Has meltdowns in the home/school/community setting Never	Has meltdowns in the home/school/community setting Sometimes or Partially	Has meltdowns in the home/school/community setting Usually or Always
Is physically aggressive in the home/school/community setting	Is physically aggressive in the home/school/community setting Never	Is physically aggressive in the home/school/community setting Sometimes or Partially	Is physically aggressive in the home/school/community setting Usually or Always
Is more active or restless than peers	Is more active or restless than peers Never	Is more active or restless than peers Sometimes or Partially	Is more active or restless than peers Usually or Always
Swears	Swears Never	Swears Sometimes or Partially	Swears Usually or Always
Sensitive/uncomfortable with others touching him or her	Sensitive/uncomfortable with others touching him or her Never	Sensitive/uncomfortable with others touching him or her Sometimes or Partially	Sensitive/uncomfortable with others touching him or her Usually or Always
Displays behaviors that cause injury to self	Displays behaviors that cause injury to self Never	Displays behaviors that cause injury to self Sometimes or Partially	Displays behaviors that cause injury to self Usually or Always
Displays behaviors that cause injury to others	Displays behaviors that cause injury to others Never	Displays behaviors that cause injury to others Sometimes or Partially	Displays behaviors that cause injury to others Usually or Always
Intentionally destroys property	Intentionally destroys property Never	Intentionally destroys property Sometimes or Partially	Intentionally destroys property Usually or Always
Has irrational fears of ordinary situations/sounds/objects	Has irrational fears of ordinary situations/sounds/objects Never	Has irrational fears of ordinary situations/sounds/objects Sometimes or Partially	Has irrational fears of ordinary situations/sounds/objects Usually or Always
Has tics (twitching, head shaking)	Has tics (twitching, head shaking) Never	Has tics (twitching, head shaking) Sometimes or Partially	Has tics (twitching, head shaking) Usually or Always
Has pica behaviors (eating non edible items)	Has pica behaviors (eating non edible items) Never	Has pica behaviors (eating non edible items) Sometimes or Partially	Has pica behaviors (eating non edible items) Usually or Always

Question Title

* 1. ASD as primary diagnosis is required. Applications will not be considered until proper diagnosis is received. Email diagnosis document to asggc@yahoo.com. Please confirm acknowledgement of this policy.

Question Title

* 2. Participant Full Name

Question Title

* 3. Participant DOB

Question Title

* 4. Participant Age

Question Title

* 5. Medical Needs/Concerns/Diagnoses. If none, answer "none".

Question Title

* 6. Assistance** For those requiring one on one assistance, a parent/guardian may be needed to provide assistance to participant

Question Title

* 7. Communication

Question Title

* 8. Is participant prone to wandering/running/eloping/leaving the area without permission?

Question Title

* 9. Is participant independent in toileting and associated use of facilities? (button/zip pants, wipe, recognize need to use the restroom and seek assistance locating it).

Question Title

* 10. Fine Motor

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* 11. Gross Motor

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* 12. Self Care

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* 13. Communication

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* 14. Comprehension

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* 15. Behavior

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* 16. Relating to Others

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* 17. List anything that motivates the participant.

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* 18. What type of educational program is the participant currently enrolled? If enrolled in a program, what support do they receive?

Question Title

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* 20. Contact information for person completing the form

* 6. Assistance
** For those requiring one on one assistance, a parent/guardian may be needed to provide assistance to participant