Social Circles Information and Application Packet

Social Circles ProgramPlease see the enclosed information and application for more information... The Baylor Autism Resource Clinic Social Circles ProgramBaylor University graduate stude

Social Circles Program

Please see the enclosed information and

application for more information.

Circle One: Fall/Spring Year: _

The Baylor Autism Resource Clinic Social Circles Program

Baylor University graduate students in the School Psychology program will provide social skills lessons to selected participants under the

supervision of Kristen Mainor, Ed.S., Licensed Specialist in School

Psychology and Dr Julie Ivey-Hatz.

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

autism@baylor.edu

(254) 537-1042

Application Instructions

The following documents must be complete:

 Application

 Parental/Legal Guardian Release (for minor participants only)

 Medical Information & Release

 Confidentiality Protection Form

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

bcdd@baylor.edu

Phone: (254) 537-1042 Fax: (254) 224-6633

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 & Father Mother Father 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: Independent Needs Reminders/Instruction Needs 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 _ Mild Moderate Severe 2 _ Mild Moderate Severe 3 _ Mild Moderate Severe 4 _ Mild Moderate Severe 5 _ Mild Moderate Severe 6 _ Mild Moderate Severe 7 _ Mild Moderate Severe 8 _ Mild Moderate Severe 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 bcdd@baylor.edu