Autism Program Application Step 1 of 17 5% 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* 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 Other Please 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 Ophthalmologist Professional 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 Past Repeats questions instead of answering them Current Past Hard to understand what s/he is saying Current Past Unusual tone and pitch Current Past Has language of his/her own (sounds like foreign language) Current Past Doesn’t seem to understand what is said to him without gestures Current Past Often ignores what is said to him/her (speech) Current Past Afraid of certain sounds Current Past Really likes certain sounds (for example, music or motors) Current Past Takes your hand for help, or leads you to what s/he wants Current Past Relating With Other PeoplePrefers to be by self Current Past In "world of his/her own" Current Past Generally ignores people Current Past Aloof, distant Current Past "Clings" to people First Choice Second Choice Third Choice Doesn't recognize parents Current Past Very fearful of strangers Current Past Doesn't interact with other peers Current Past Prefers to interact with younger children Current Past ImitationDoesn't imitate gestures (physical imitation) Current Past Doesn’t repeat words said to him/her (verbal imitation) Current Past Doesn’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 Past Stares vacantly around the room Current Past Often doesn’t look at anything Current Past Very interested in small parts of an object Current Past Likes to look at self in the mirror Current Past Likes to look at shiny objects Current Past Stares at parts of body – i.e., hands Current Past Seems to look at things out of the corner of his/her eyes and not looking directly at them Current Past Plays with turning lights on and off Current Past Other SensesLicks objects Current Past Tries to chew or eat objects which are not supposed to be eaten (i.e., clay) Current Past Doesn’t seem to notice if something tastes bad Current Past Smells objects not usually smelled or smells unfamiliar objects Current Past Doesn’t notice pains as much as most people Current Past Doesn’t recognize parents Current Past Overreacts to pain Current Past Likes vibrations Current Past Emotional ResponseTemper tantrums Current Past Moods change very quickly, sometimes for no apparent reason Current Past Often has a blank expression on face – little responses to what is happening around him/her Current Past Over-responds to situations Current Past Laughs or smiles for no apparent reason Current Past Doesn't recognize parents Current Past Cries or seems sad for no apparent reason Current Past Doesn’t interact with other peers Current Past Body MovementsRocks from foot to foot Current Past Rocks in bed or chair Current Past Holds hands in strange positions Current Past Wiggles hands or fingers in strange ways Current Past Has unusual posture Current Past Bites him/herself Current Past Bangs head Current Past Walks on tiptoes Current Past Nothing unusual about his/her use of his/her body Current Past Use of Materials, ObjectsHas strong attachment to a particular object Current Past Spins wheels or small parts of objects Current Past Dangles strings, straws, etc. Current Past Doesn’t use objects for intended purposes Current Past Gets involved in a simple activity for long periods of time Current Past Reaction to ChangeGets upset when routine changes Current Past Will wear only certain clothes Current Past EatingLikes only a few foods Current Past Has trouble chewing Current Past Poor appetite Current Past Aloof, distant Current Past Anxiety and FearsGets overly upset by certain things or situations Current Past Not easily calmed Current Past Stays upset for a long time Current Past ManageabilityEngages in ongoing problem behaviors First Choice Second Choice Third Choice Engages 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.