Social Butterfly Registration Form - The Behaviour Change Clinic

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About Us
- Our Approach
Services
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Contact Us
- Employment and Volunteer Opportunities

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Social Butterflies Registration Form

Child's full name

Child's date of birth

Parent/Guardian Name

Address

Emergency Telephone number

How would you like to be invoiced?

Autism Funding (completed and approved RTP required) Cheque/Cash Distributed Learning (DL)

Child Information

Does your child have any 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

What are your child's interests? What motivates him/her?

Skills Assessment

Please rate each area to the best of your ability. Note: we may offer you a place on our Social Caterpillars or Social Butterflies group pending this assessment.

Communication

My child can request at least 10 different items using words, PECS, or AAC.

Always Sometimes Never

My child can ask for information using WH questions (e.g. what's your name, where is my juice?)

Always Sometimes Never

My child can politely request to stop an undesirable activity, or remove something aversive.

Always Sometimes Never

My child can give directions, instructions, or explanations as to how to do something or how to participate in an acitvity.

Always Sometimes Never

My child can request for others to attend to them (e.g. "Listen to me", "Here's what happened")

Always Sometimes Never

Behaviour

My child is typically cooperative with adult instructions in a group setting

Always Sometimes Never

My child runs away or leaves a setting without permission.

Always Sometimes Never

My child hits or throws items at others.

Always Sometimes Never

My child hits themselves or hits a part of their body against an object.

Always Sometimes Never

My child can transition between activities with warnings without engaging in challenging behaviour (e.g. hitting others

Always Sometimes Never

Accuracy of Information

I agree that the information contained in this form is accurate.

Distressed Behaviour

I understand that this group is not designed for children who engage in severe distressed behaviours (such as running away, or physical aggression).

Payment Policy

I understand that full payment and/or approval from the funding source is required before the start date (only signed RTP's are needed).

I consent for The Behaviour Change Clinic to take photos and/or videos of my child and use them for advertising and/or training purposes.

Yes No

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