Game On!

Autism SA provides a variety of group programs. In order to allocate positions equitably an eligibility and priority of access criteria will be adhered to in allocating individual participation. The information gathered on this form will assist Autism SA determine group membership. Completion of this form does not guarantee a place in the group.

Child’s Name:______Gender:______

Diagnosis: ______

Address:______

Phone number: ______

Parents/carers name: ______

Questions:

  1. What other environments is your child attending? For example kindergarten/school/child care

______

  1. How old is your child?

______

  1. What services has your child received from Autism SA over the last year?

______

______

______

  1. Is your child involved in any community/sporting programs?

______

______

______

  1. Please describe your family’s support network? (including family, friends, school, church etc.)

______

______

______

  1. Has your child been excluded from a school or community group/activity?

______

______

______

  1. Does your child have challenging behaviours? Yes/No

If yes, what are the behaviours of concern?

______

______

______

______

  1. How does your child communicate? (i.e. verbal communication, PECS, non verbal etc.)

______

______

______

  1. This program may require your child to participate in communication & written activities. Please indicate below their capacity to engage in these activities?

(This will help us to adapt the program to level the group is at)

COMMUNICATION:

Can communicate when they need help

Will sometimes ask for help

Does not know how to ask for help

Needs tasks broken down into steps: 1-2 3-4

Needs time to process verbal information. How long? ______

Can contribute to group discussion

LITERACY:

Refuses to write and struggles with using a pen or pencil

Will only attempt to write a sentence when necessary but needs prompting

Can comfortably write 3-4 sentences & is willing to use these skills.

  1. What is your child’s preferred way to learn?

______

  1. Do you have exceptional family circumstances that need to be taken into consideration? (e.g. sole parent, more than one child with a disability) Yes/No

If yes, please provide details.

______

______

______

______

  1. This program requires that your child participates in sessions each week. Please indicate your child’s willingness to participate in the program on a regular basis.

Low12345High

Please return this Participant Information Form to register your interest in the reply paid envelope or:

Greg Healy

Autism SA

Reply Paid 304

MARLESTON DC SA 5033

Client F32 – Priority of Access Information For Groups Page 1 of 3