Aspirations Enrollment Form

ASPIRATIONS ENROLLMENT FORM

Please complete the following information:

Participant’s name:Sex:MaleFemale

Today’s date:Ethnicity:

Participant’s date of birth: Age:

Participant’s address:

Participant’s phone number: Participant’s email address:

Participant’s Diagnoses:

(Please enclose proof of diagnosis, e.g. a recent neuropsychological report, letter from psychiatrist / psychologist etc.).

Diagnosed by:Date of diagnoses:

Name of Participant’s school / employer (if any):

Please list all medications your son/daughter is currently taking:

Medication / Reason

Has your son/daughter completed an IQ test? If yes, what were the scores (please send copy of report if available)?

Full scale IQ:

Verbal IQ:

Performance IQ:

Name of test:

Date of test:

What other programs (if any) has your son/daughter participated in during the last five years (e.g. drama club, social skills groups)?

What other services (if any) has your son/daughter received during the last five years (e.g. speech therapy, counseling, sensory integration)?

Parent Information:

Parent(s) / Guardian’s name(s):

Parent(s) / Guardian’s address(es) (if different from above):

Parent(s) / Guardian’s telephone number(s):

Parent(s) / Guardian’s email address(es):

Mother’s name and place of employment (if applicable):

Father’s name and place of employment (if applicable):

How did you hear about Aspirations?

Why would you like your son/daughter to participate in Aspirations?

Do you have any questions or concerns about Aspirations?

ASPIRATIONS DEVELOPMENTAL PROFILE

Communication Skills

Does your son/daughter:

Never / Sometimes / Often
Initiate a conversation
Take turns in conversation without monopolizing
Avoid interrupting conversation partner
Remain on topic
Make appropriate eye contact
Maintain appropriate personal space
Choose appropriate topics of conversation
Accurately convey messages
Recognize facial expressions of others
Understand sarcasm
Understand when someone is joking
Understand metaphors

Reading and Writing

Can your son/daughter:

Yes / No
Read and comprehend complex text of reasonable length (e.g.
newspaper articles)
Use a dictionary
Write letters to others
Write advanced letters (e.g. business letters)

Socialization

Does your son/daughter:

Yes / No
Have close friends
Have an interest in making friends
Avoid people
Initiate conversations with people
Respond to conversations of others

Behavior

Does your son/daughter:

Never / Sometimes / Often
Exhibit verbal aggression
Exhibit physical aggression
Have temper tantrums / emotional outbursts
Exhibit high level of anxiety
Exhibit high level of frustration
Have preoccupations with objects or activities (please specify below)

Comments:

Please complete your son/daughter’s education history:

Name and address of school(s) attended

/

Course of study

/ Year(s) / Grade(s) achieved

Please complete your son/daughter’s employment history (include work experiences):

Name and address of previous employer(s)

/

Job title and brief description of duties

/ Period of employment / Reason for leaving

ASPIRATIONS CURRICULUM QUESTIONNAIRE (PARENTS)

Name:

The purpose of this questionnaire is to help us better understand your son/daughter’s needs. Your responses may be incorporated in to our curriculum to ensure that topics covered are relevant to each individual Aspirations group.

Please check topics below which you would like us to cover during the Aspirations sessions. Also, please place an * next to the 3 most important topics to you.

Consideration of appropriate employment / career
Consideration of attending college / further education
Negotiating relationships with supervisors and co-workers / teachers
Negotiating relationships with family members, neighbors etc.
Friendships
Sexuality and opposite sex relations
Birth control, STDs
Marriage and children
Verbal communication skills (e.g. conversational turn taking, initiating conversations etc.)
Non-verbal communication skills (e.g. greater awareness of own NVC and improved ability to understand NVC of others)
Empathy (e.g. understanding others’ thoughts, emotions etc.)
Understanding how their behavior influences the opinions of others towards them
Teasing / bullying
Greater understanding of autism spectrum disorders
Self-awareness
Self-esteem, self-acceptance
Self advocacy skills
Achieving greater independence
Financial responsibility
Independent living
Nutrition / healthy lifestyle
Drug use, smoking, alcohol
Personal hygiene
Behavioral difficulties (e.g. loss of temper, anger, frustration)

Please list any additional topics not covered above: