Supporting Success at Mealtimes- Interest Form

Please complete this form to express interest in our virtual parent training program for parents of an autistic child with mealtime/ feeding difficulties. The goal of this program is to help parents learn techniques to improve family mealtimes.

The program will take place on Thursdays from 12-1 pm, beginning March 5th, for 6 weeks. Sessions are 60 minutes in length and will take place via Zoom.

In order to be eligible for this program, you must be (a) a parent or caregiver of a child with autism spectrum disorder between the ages of 6 and 10 years, and (b) have a child with feeding/mealtime challenges.

We look forward to hearing from you!

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1. Your Full Name:

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2. Your Child's Full Name:

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3. County of Residence (Required.)

Albany

Columbia

Fulton

Greene

Hamilton

Montgomery

Rensselaer

Saratoga

Schoharie

Schenectady

Warren

Washington

Other (please specify)

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4. Child's Date of Birth

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5. Does your child have an autism spectrum diagnosis?

Yes, my child has an official autism spectrum diagnosis

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6. Child's Language Ability

No current gestures or verbal language

Uses gestures, but no current verbal language (Hand-leading, signs, pointing, etc.)

1-2 word phrases

3-4 word phrases

Sentences

Other (please specify)

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7. Child's Classroom Type

General Classroom

Integrated Classroom

Self-Contained Classroom

Other (please specify)

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8. Please rank which category best describes your child's current feeding difficulties.

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9. Has your child ever been referred for a swallow study?

Yes

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10. If yes, please describe the results of the study (e.g., results indicated child chokes on thin liquid)

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11. Contact Information:

Email Address

Phone Number

Supporting Success at Mealtimes- Interest Form

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* 1. Your Full Name:

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* 2. Your Child's Full Name:

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* 3. County of Residence (Required.)

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* 4. Child's Date of Birth

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* 5. Does your child have an autism spectrum diagnosis?

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* 6. Child's Language Ability

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* 7. Child's Classroom Type

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* 8. Please rank which category best describes your child's current feeding difficulties.

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* 9. Has your child ever been referred for a swallow study?

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* 10. If yes, please describe the results of the study (e.g., results indicated child chokes on thin liquid)

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* 11. Contact Information:

1. Your Full Name:

2. Your Child's Full Name:

3. County of Residence (Required.)

4. Child's Date of Birth

5. Does your child have an autism spectrum diagnosis?

6. Child's Language Ability

7. Child's Classroom Type

8. Please rank which category best describes your child's current feeding difficulties.

9. Has your child ever been referred for a swallow study?

10. If yes, please describe the results of the study (e.g., results indicated child chokes on thin liquid)

11. Contact Information: