(Delaware County Referrals, fax to: (484) 454-8813 ATTN: Nicole Radolovic – ASP)
(Philadelphia County Referrals, fax to: (267) 713-4134 ATTN: Melissa Bowen – ASP)
AFTER-SCHOOL SERVICES
APPLICATION WORKSHEET
FORM COMPLETED BY DATE OF APPLICATION______
CHILD INFORMATION
LAST NAME ______FIRST NAME ______
DATE OF BIRTH _____/_____/_____ AGE _____ SOCIAL SECURITY # _____-_____-_____
CLIENT HEIGHT _____FT. _____IN.CLIENT WEIGHT (APPROX.) ______SEX ______
MOTHER’S NAME ______FATHER’S NAME ______
GUARDIAN’S NAME ______RELATIONSHIP ______
ADDRESS ______ZIP ______
HOME PHONE # ( ) ______WORK PHONE # ( ) ______
SCHOOL INFORMATION
SCHOOL DISTRICT ______SCHOOL ______
GRADE LEVEL ______SPECIAL EDUCATION: Y OR N
REFERRAL INFORMATION
PERSON MAKING REFERRAL ______TITLE ______
AGENCY ______PHONE # ( ) ______
INSURANCE INFORMATION
MA RECIPIENT # (10 DIGIT) ______DELCARE/MBH Y OR N
EVS DATE: ______CBH Y OR N
CURRENT MENTAL HEALTH SERVICES RECEIVED:
¨ OPS ¨ EAS
¨ BHRS ¨ Other: ______
¨ Family Based
SELF-TOILETING ABILITY: YES OR NO
SELF-FEEDING ABILITY: YES OR NO
Does the referring child have an Autism Diagnosis: YES OR NO
Communication Methods (Check those that apply)____
q Verbal
q Picture Exchange Communication System (PECS)
q Sign Language
q Extremely limited speech
q Completely non-verbal
q Additional Information: ______
______
Sensory Issues (Check those that apply)
q Loud Sounds
q Lighting (Too bright and/or dark)
q Water
q Temperature (Too hot and/or cold)
q Art Materials (e.g., paints, etc.) ______
______
q Large Groups
q Other (Please specify): ______
Behavioral Issues (Check those that apply)
q Bangs head
q Bites hand
q Scratches Self
q Hits Others
q Elopes/Runs Away
q Bites Others
q Pinches Others
q Scratches Others
q Verbally Instigates Others
q Additional Information:
q Medical Issues (Check those that apply)
q Seizure Activity Hearing Aid(s)
q Eye Glasses Protective Headgear
q Allergies (Please Specify): ______Other (Please Specify):______
ASP Client Checklist (Please check all that apply.)
1. Aggressive Behaviors (behaviors that occurred within the last 6 months.)
· Aggression that causes injury to others, animals, or self [ ]
Examples: Biting, broken bones, open wounds, etc.
· Use of or possession of weapons. [ ]
Examples: Bringing a knife to school within the last 6 months
· Homicidal behaviors [ ]
· Daily incidents of aggression [ ]
Example: Attempting to physically hurt someone at least once per day
2. Clients that have been placed in a higher level of care.
· Client in RTF in last 6 months [ ]
· Client in partial hospitalization in last 3 months [ ]
· Client in inpatient in last 3 months [ ]
3. Inappropriate sexual behaviors within the last year [ ]
· Masturbation in public [ ]
· Intentional inappropriate touching of peers [ ]
4. Fire setting within the past year [ ]
5. Clients involved with JPO [ ]
6. Active drug or alcohol use/abuse [ ]
7. Client is 12 years or older and not toilet trained [ ]
8. Client has no formal means of communication [ ]
9. Client is unable to self feed [ ]
10. Elopement (occurring on a weekly basis) [ ]
11. Client has not yet attended kindergarten [ ]
HOW DID YOU HEAR ABOUT THE AFTERSCHOOL PROGRAM:
¨ CGRC Employee ¨ CGRC Website ¨ Other: ______
¨ Facebook Ad ¨ Flyer