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: Guardian’s Name: Address: Gender: (LAST) (FIRST) (MIDDLE) (LAST) (FIRST) (MIDDLE) (STREET) (CITY) _ Ethnicity: _ Date of Birth: (STATE) (MM/DD/YYYY) (ZIP) Grade Level (if applicable): 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 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 – 10 recognizable words 10+ 1-word phrases – 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): _ Mild Moderate Severe _ Mild Moderate Severe _ Mild Moderate Severe _ Mild Moderate Severe _ Mild Moderate Severe _ Mild Moderate Severe _ Mild Moderate Severe _ 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 ... 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... 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... 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