Summer 2012 Application

1. Tell us about your child

 
 17% 
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1. Your child's first and last name?
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2. Demographics
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3. What is his/her diagnosis?
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4. Briefly describe his/her social difficulties?
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5. What are the typical triggers that make your child upset?
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6. What is an effective way to intervene when your child becomes upset?
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7. What services is your child currently receiving outside of school?
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8. Describe his/her academic difficulties that you want him/her to improve over the summer?
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9. Briefly describe his/her strengths?
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10. What incentives, if any, motivate your child (e.g., toys, money, food, TV, video games, etc...)
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11. Any current or history of aggression, running away or destruction of property?
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12. Any self-care issues (e.g., toileting, changing clothes, etc...)
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13. Any medical or physical problems? Allergies?
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14. Any food issues or dietary restrictions?
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15. Does he/she take medication? If yes, please describe with names of medications, dosages, times of dosages, etc...
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