Child Registration for FOCUS cohort 5

ABA Liverpool Club/School

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100% of survey complete.

Please fill in to register your child for the FOCUS Liverpool, autism Saturday Club that uses the principles of ABA (Applied Behaviour Analysis). Children will need to attend an assesment on the 18th & 19th February. This will approximately take 1 hour.

The next intake will take place in on the 11th March 2017

Please register your interest by filling the below questionnaire.

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* 1. Who are you?

Parent / Carer

Consultant

Therapist

Other (please specify)

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* 2. Contact details

Name

Company

Address

Address 2

City/Town

County

Postal Code

Email Address

Phone Number

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* 3. What is your child's details?

Name

Gender

Age

Date of Birth

Are they currently accessing any ABA input?

Are they currently under any other kind of intervention? if so what?

How long have you been doing it?

Contact details of the person leading any intervention?

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* 4. Does your child have a diagnosis of autism?

Yes

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* 5. Does your child attend any of the following?

Mainstream School

Special Educational Needs (SEN) school

Pre-school

Nursery

Home Schooled

Other

Do they receive any extra provision?

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* 6. How does your child communicate with you? Please tick all that apply to your child.

Gestures

Pointing

Leading

Pictures

Picture Exchange Communication System (PECS)

Makaton Sign Language

British Sign Language

Vocals

No communication

Other (please specify)

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* 7. Does your child engage in challenging behaviours? Please tick all that apply.

Self-Injurious Behaviour (SIB)

Physical Aggression

PICA

Property Damage

Verbal Aggression

Absconding

No challenging behaviours

Other (please specify)

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* 8. Please tick one box which applies best to your child.

My child will play with other children and currently joins in with group work

My child engages in parallel play with other children.

My child prefers not to engage in group work or play with other children

Other (please specify)

Child Registration for FOCUS cohort 5

ABA Liverpool Club/School

Question Title

* 1. Who are you?

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* 2. Contact details

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* 3. What is your child's details?

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* 4. Does your child have a diagnosis of autism?

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* 5. Does your child attend any of the following?

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* 6. How does your child communicate with you? Please tick all that apply to your child.

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* 7. Does your child engage in challenging behaviours? Please tick all that apply.

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* 8. Please tick one box which applies best to your child.

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* 9. Why would you like your child to attend FOCUS and what are your expectations?

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* 10. Do you have any other comments, questions, or concerns?