Social Butterflies Registration Email Child's full name Child's date of birth Parent/Guardian Name Address Emergency Telephone number How will you be paying? Autism Funding Cheque/Cash DL funding Other Which session(s) would you like to register for? May 1-29, 2024 Is your child aware that they have ASD? Yes No My child does not have ASD Child Information Does your child have any allergies or medical conditions that we should be aware of? If yes, please describe. Will your child be taking any medication during group time? Yes No Other How does your child communicate? Vocal/Verbal Minimally verbal AAC Others Please upload your child's IEP I will email my child's IEP to tana@thebehaviourchangeclinic.ca File uploaded Yes, I confirm What are your child's interests? What motivates him/her? It's important that we address any concerning behaviour early on to prevent any potential harm, and provide effective support and guidance to help your child manage their emotions and behavior in a positive and safe manner. Does your child engage in any of the following distressed behaviours: Harm towards others (e.g. hitting, biting) Self-injury (harm to self) Bolting (running away) Safety concerns: climbing, throwing No, my child does not engage in any of these behaviours Skills Assessment Please rate each area to the best of your ability. We use this information to determine the appropriateness of the group for your child and to create individualized goals.. My child identifies emotions in themselves. Almost Always Often Sometimes Almost Never My child can identify emotions in others. Almost Always Often Sometimes Almost Never My child can justify emotions once identified. Almost Always Often Sometimes Almost Never My child demonstrates empathy and affection toward peers. Almost Always Often Sometimes Almost Never My child refrains from engaging in aggression towards others. Almost Always Often Sometimes Almost Never My child refrains from demonstratng aggression towards themselves. Almost Always Often Sometimes Almost Never My child interprets body language. Almost Always Often Sometimes Almost Never Self-Regulation My child can self-regulate when tense or upset. Almost Always Often Sometimes Almost Never My child can self-regulate when energy is high. Almost Always Often Sometimes Almost Never My child can accept not being first in a game or activity. Almost Always Often Sometimes Almost Never My child can accept losing without becoming upset/angry. Almost Always Often Sometimes Almost Never My child can say "no" in an acceptable way to things they don't want to do. Almost Always Often Sometimes Almost Never My child can accept "no" without becoming upset or angry. Almost Always Often Sometimes Almost Never Flexibility My child accepts making mistakes without becoming upset or angry. Almost Always Often Sometimes Almost Never My child accepts consequences of their behaviour. Almost Always Often Sometimes Almost Never My child accepts unexpected changes. Almost Always Often Sometimes Almost Never Problem Solving My child can identify problems (in social situations). Almost Always Often Sometimes Almost Never My child can generate solutions to problems. Almost Always Often Sometimes Almost Never My child can carry out solutions by negotiating or compromising. Almost Always Often Sometimes Almost Never My child understands the impact their behaviour has on peers. Almost Always Often Sometimes Almost Never Conversation Skills My child can initiate conversation when it is appropriate to do so. Almost Always Often Sometimes Almost Never My child can initiate conversation around specific topics.. Almost Always Often Sometimes Almost Never My child can ask WH questions (who, what, when , where, why) Almost Always Often Sometimes Almost Never My child can respond to WH questions (who, what, when , where, why) Almost Always Often Sometimes Almost Never My child makes a variety of comments related to the topic during conversation. Almost Always Often Sometimes Almost Never My child introduces themselves to someone new. Almost Always Often Sometimes Almost Never My child ends conversations appropriately.. Almost Always Often Sometimes Almost Never My child maintains appropriate proximity to their conversational partner. Almost Always Often Sometimes Almost Never My child orients their body towards the speaker. Almost Always Often Sometimes Almost Never My child attends to a person's non-verbal language; understands what is communicated. Almost Always Often Sometimes Almost Never My child interjects appropriately. Almost Always Often Sometimes Almost Never My child gives compliments to peers. Almost Always Often Sometimes Almost Never My child appropriately receives compliments. Almost Always Often Sometimes Almost Never My child apologizies independently. Almost Always Often Sometimes Almost Never Waivers and Releases I understand that the child to adult ratio during group time is 4:1 and I agree that my child does not engage in behaviour that poses a risk to themselves or others. Yes, I agree No, I do not agree My child will require 1:1 support for this group I am aware that there are risks associated with the participation in Let's Play!, including the risk of injury, and I consent to my child’s participation in spite of such risks. I acknowledge that it is my responsibility to advise The Behaviour Change Clinic of any medical or other conditions which may affect my child’s participation in Let's Play! and have listed them above. I understand that I am responsible for immediately notifying staff/supervisor of any changes to the above information. In the event that my child requires medical attention, I consent to my child being transported to the nearest emergency centre, including by ambulance if necessary. I have read this form and understand and accept its terms. Yes, I agree No, I do not agree I consent to The Behaviour Change Clinic taking photos and/or videos of my child for advertising and/or training purposes. Yes, I agree No, I do not agree I understand that either myself or a designated contact will pick my child up from their group on time. Late pick ups are charged at a rate of $65/hr. Yes, I agree No, I do not agree I acknowledge that there are no refunds should my child be removed from the group and/or be unable to attend sessions. Yes, I agree No, I do not agree I understand that the group fee will be charged at once, and payment or RTP submission must be received at least 1 day prior to the start of the group. Yes, I agree No, I do not agree Send
