Young Adult Social Virtual Group - Intake Registration Form for January 2021 group

YAST - Virtual January to March 2021 Registration

Please complete this registration intake form.

*Young Adult Social Time group is meant for individuals (18 to 28 years old) who are already able to access the community independently and who can participate in the group without 1:1 support. Most sessions will be virtual through Zoom with games, activities time to chat, and an occasional social outing - weather and COVID permitting. (One outing will be a scheduled trip to McNabb Corn Maze).

Once your registration is received one of the staff members from Young Adult Social Time group will be in contact with you prior to starting group sessions. If you have any questions, please call Kimberlee @ 250-618-5640 or Kimberlee@nanaimocdc.com

This group is supported by The Allen and Loreen Vandekerkhove Family Foundation, Autism BC & Nanaimo Child Development Centre.

Thank you for completing all questions on this intake form. Information will be used only for the purposes of this group and not shared outside the YAST staff and organizers.

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* 1. Please tell us about yourself:

Full Name

Age

Address

City/Town

Postal Code

Email Address

Phone Number (home)

Cell Number

Diagnoses, if any:

Allergies

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* 2. Any Medical concerns that could be present while you are attending group, if yes please describe so staff can support you in best way possible?

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* 3. Your Hobbies or Interests? (What do you like to do in your free time)

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* 4. Do you need help with any of the following? (Please check all that apply - this info will be for public outings)

Wandering

Responding positively to Authority

Physical boundaries

Following group ground rules

Traveling on local Transit

Being in public settings - community outings

Toileting

None of the above

Need help with: (something not listed above)

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* 5. Please check any of the following that affects you?

Large groups of people / crowds

Loud noises - Loud Environments

Smells

Lighting

None of the above

Something that is not mentioned above that affects you when with others?

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* 6. What do you hope will happen for you by attending this group for 8 weeks:

Make new friends

Learn new things

Have fun

Learn more about our community

Or I'd like to:

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* 7. Emergency Contact info: (Contact person over the age of 18 in case of emergency)

Name

Relationship to you

Address

City/Town

Phone Number

Email Address

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* 8. Additional Person to contact with program info if unable to contact you?

Name

Phone Number

Email Address

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* 9. How did you find out about Young Adult Social Time?

From a community Agency (Please list in comment box which one)

Facebook

Individual - Family Member

Individual - Support worker

Individual - Friend

Which Agency did you learn about group from:

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* 1. Please tell us about yourself:

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* 2. Any Medical concerns that could be present while you are attending group, if yes please describe so staff can support you in best way possible?

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* 3. Your Hobbies or Interests? (What do you like to do in your free time)

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* 4. Do you need help with any of the following? (Please check all that apply - this info will be for public outings)

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* 5. Please check any of the following that affects you?

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* 6. What do you hope will happen for you by attending this group for 8 weeks:

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* 7. Emergency Contact info: (Contact person over the age of 18 in case of emergency)

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* 8. Additional Person to contact with program info if unable to contact you?

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* 9. How did you find out about Young Adult Social Time?

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* 10. Thank you for completing all questions on this form, if there is anything else you'd like us to know please tell us in comment box below :-)