Autism Program ApplicationStep 1 of 175%Participant InformationParent Guardian Name* First Last Participant's Name* First Middle Last Nickname (Likes to be called)Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Participant's Date of Birth* Date Format: MM slash DD slash YYYY Gender*FemaleMaleParticipant currently lives with*Occupation of Parent/Guardian*How did you learn about the program?Mark all that apply Brochure Word of mouth Advisory Committee member Program Manager/staff member OtherPlease specifyPlease list the participant's brothers and sistersNameAgeGradeGenderHealth or other issues Medical HistoryHas your child seen any of these professionals in the last six months?Mark all that apply Family Physician Neurologist Dietician Psychiatrist Psychologist Social Worker Speech Pathologist Audiologist Physical Therapist Occupational Therapist Ear, Nose, Throat Specialist OphthalmologistProfessional InformationName of ProfessionalStreet Address Is your child currently taking medications and/or vitamins?Medication/vitaminAdministered by (i.e., injection, pill)Dosage (mg)Schedule (i.e., time daily) Past medications taken for disability-related purposes (exclude current)MedicationDatesReasonEffectiveness At what age did you first think something was wrong with your child?At what age did you seek professional help?From whom did you seek professional help? (Name and address)Has any other family member been diagnosed with a disability?NoYesPlease explain SpeechReceptive Languageat age appropriate levelbelow age appropriate levelExpressive Languageat age appropriate levelbelow age appropriate levelChild is verbalYesNoChild uses sign languageYesNoChild uses Picture Exchange Communication System (PECS)YesNoChild uses Alternate Augmentative Communication SystemYesNoPlease specifyNo speech currently Current PastRepeats questions instead of answering them Current PastHard to understand what s/he is saying Current PastUnusual tone and pitch Current PastHas language of his/her own (sounds like foreign language) Current PastDoesn’t seem to understand what is said to him without gestures Current PastOften ignores what is said to him/her (speech) Current PastAfraid of certain sounds Current PastReally likes certain sounds (for example, music or motors) Current PastTakes your hand for help, or leads you to what s/he wants Current Past Relating With Other PeoplePrefers to be by self Current PastIn "world of his/her own" Current PastGenerally ignores people Current PastAloof, distant Current Past"Clings" to people First Choice Second Choice Third ChoiceDoesn't recognize parents Current PastVery fearful of strangers Current PastDoesn't interact with other peers Current PastPrefers to interact with younger children Current Past ImitationDoesn't imitate gestures (physical imitation) Current PastDoesn’t repeat words said to him/her (verbal imitation) Current PastDoesn’t repeat words generally, but usually will do what he/she’s asked to do Current Past Visual ResponseOften avoids looking at people when they talking to him/her by lights-stares at certain ones Current PastStares vacantly around the room Current PastOften doesn’t look at anything Current PastVery interested in small parts of an object Current PastLikes to look at self in the mirror Current PastLikes to look at shiny objects Current PastStares at parts of body – i.e., hands Current PastSeems to look at things out of the corner of his/her eyes and not looking directly at them Current PastPlays with turning lights on and off Current Past Other SensesLicks objects Current PastTries to chew or eat objects which are not supposed to be eaten (i.e., clay) Current PastDoesn’t seem to notice if something tastes bad Current PastSmells objects not usually smelled or smells unfamiliar objects Current PastDoesn’t notice pains as much as most people Current PastDoesn’t recognize parents Current PastOverreacts to pain Current PastLikes vibrations Current Past Emotional ResponseTemper tantrums Current PastMoods change very quickly, sometimes for no apparent reason Current PastOften has a blank expression on face – little responses to what is happening around him/her Current PastOver-responds to situations Current PastLaughs or smiles for no apparent reason Current PastDoesn't recognize parents Current PastCries or seems sad for no apparent reason Current PastDoesn’t interact with other peers Current Past Body MovementsRocks from foot to foot Current PastRocks in bed or chair Current PastHolds hands in strange positions Current PastWiggles hands or fingers in strange ways Current PastHas unusual posture Current PastBites him/herself Current PastBangs head Current PastWalks on tiptoes Current PastNothing unusual about his/her use of his/her body Current Past Use of Materials, ObjectsHas strong attachment to a particular object Current PastSpins wheels or small parts of objects Current PastDangles strings, straws, etc. Current PastDoesn’t use objects for intended purposes Current PastGets involved in a simple activity for long periods of time Current Past Reaction to ChangeGets upset when routine changes Current PastWill wear only certain clothes Current Past EatingLikes only a few foods Current PastHas trouble chewing Current PastPoor appetite Current PastAloof, distant Current Past Anxiety and FearsGets overly upset by certain things or situations Current PastNot easily calmed Current PastStays upset for a long time Current Past ManageabilityEngages in ongoing problem behaviors First Choice Second Choice Third ChoiceEngages in intermittent behaviors Current Past Your Child at SchoolSchool StatusElementary SchoolMiddle SchoolHigh SchoolHome SchoolSchool NameSchool Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Teacher/Supervisor Name First Last PhoneGrade LevelClass typeRegular Classroom / No adaptationsRegular Classroom / With adaptationsPull-outResource RoomIs your child receiving any tutoring in school?YesNoHow many hours per week and in which subject?Is your child involved in any extracurricular activities?YesNoPlease explainHow did you think your child is doing academically?Does your child have any friends at school?YesNoHow do you think your child is doing socially? CommunityDoes your child enjoy going places in the community?YesNoWhere?Does your child enjoy shopping?YesNoWhere?Does your child participate in volunteer work?YesNoDoes your child enjoy participating in art projects?YesNoWhat kind of art projects? ExpectationsThe Kelly Autism Program provides educational support, social training, community involvement opportunities, and job coaching. What do you expect from the KAP if you enroll your child in our program?CommentsThis field is for validation purposes and should be left unchanged.