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

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