Please See the Enclosed Information and Application for More Information

Social Circles Program

Please see the enclosed information and application for more information.

Circle One: Fall/Spring Year: ______

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The Baylor Autism Resource ClinicSocial Circles Program

Baylor University graduate students in the School Psychology program will provide social skills lessons to selected participants under the supervision of Kristen Padilla-Mainor, Ed.S., LSSP, BCBA, Licensed Specialist in School Psychology and Dr. Eric Robinson.

One-hour sessions will be provided once per week to each child at the Baylor Clinic for Developmental Disabilities (BCDD) located at the Hillcrest MacArthur Clinic at 2201 MacArthur Drive, Suite 101, Waco, TX 76708. Baylor University campus closings and holidays will be observed. Please note that this program is NOT intended to replace school services, but instead to supplement programs that the child may be receiving.

Goals will be selected by parent/caregiver, and progress monitoring results will be provided.

Applicants must have a diagnosis of a developmental disability, including, but not limited to autism, PDD-NOS, or Rett Syndrome. The program has limited openings.

Applications will be reviewed, and accepted applicants will be placed with an available group or on the waitlist on a first come, first serve basis. Participants will be notified of acceptance and/or placement after application review.

Cost: $25 registration fee**

$25 supply fee**

$10 per session fee

**Fees subject to change

For more information, contact

(254) 537-1042

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Applications may be submitted by email, fax, or mail.

Baylor Autism Resource Clinic

Baylor University Center for Developmental Disabilities

2201 MacArthur Dr. Suite 101

Waco, TX 76708

Phone: (254) 537-1042

Fax: (254) 224-6633

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Circle One: Fall/Spring Year:______

Baylor Autism Resource Clinic (BARC) Social Circles Program Application

Participant’s Name:

(LAST)(FIRST)(MIDDLE)

Guardian’s Name:

(LAST)(FIRST)(MIDDLE)

Address:

(STREET)(CITY)(STATE)(ZIP)

Gender: _ Ethnicity:______Date of Birth:Grade Level (if applicable):

(MM/DD/YYYY)

Parent/Caregiver Phone Number (cell phone, if available):

Home Phone Number: Work Phone Number:

Parent/Guardian Email:

Diagnosis:

Participant Lives with: Mother FatherMotherFather

Other/Legal Guardian (please specify):

List other children in the household:

Name: Age:Name: Age:

Name: Age:Name: Age:

Name: Age:Name: Age:

How did you hear about the Social Skills program?

Which days of the week and times do you prefer for your child to attend? Please note that daytime appointments are available and highly encouraged.

Identify participant’s favorite foods, activities, items, etc.:

Please identify participant’s current skill level. Check one:

Adaptive Behavior Skills:

IndependentNeeds Reminders/InstructionNeeds Physical Assistance

Toileting______

Hand Washing______

Dressing______

Communication Skills (check all that apply):

No Speech sounds Babbles (non-words) Says 1 – 10 recognizable words

10+ 1-word phrases 2 – 3 word phrases Short sentences or more

Imitates words & sounds Echolalia (nonfunctional repeating of sounds)

Primary mode of communication is verbal language

Primary mode of communication is sign language. If yes, approximate number of signs:

Primary mode of communication is pictures/PECS. If yes, approximate number of pictures:

Primary mode of communication is electronic communication device. If yes, approx. # of buttons:

Challenging or Problem Behaviors of Concern (list and rate):

1.______MildModerateSevere

2.______MildModerateSevere

3.______MildModerateSevere

4.______MildModerateSevere

5.______MildModerateSevere

6.______MildModerateSevere

7.______MildModerateSevere

8.______MildModerateSevere

Identify current therapies the participant currently receives.

Identify and describe five high-priority goals that you would like to see your child meet during Social Circles.

OPTIONAL: Describe any unique financial needs that influence your child’s need for the Baylor Autism Clinic’s services.

What portion of the service fees would you be able to pay?______

Applications may be submitted by email, fax, or mail.

If selected, fees and all required forms will be due by the first day of Social Circles. An individualized fee schedule will be created for participants that choose to pay for sessions on a monthly basis.

Baylor Autism Resource Clinic

Baylor University Center for Developmental Disabilities

2201 MacArthur Dr. Suite 101

Waco, TX 76708

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