Summer Program Application

Child's Info

Child's Age*

Parent 1 Info

Parent 1 Home Phone

Parent 1 Phone Mobile*

Parent 1 Email*

Parent 2 Info

Parent 2 Home Phone

Parent 2 Phone Mobile

Parent 2 Email

Who is your primary clinician?

3. List your child's talents, interests, special abilities and strengths.*

4. Please describe your child's difficulties in structured settings such as the classroom, organized sports or after-school activities.*

5. Please describe your child's relationships with peers (if they have a best friend, get along well with other children, seem interested in forming friendships with others).*

If no, please indicate dates that would be missed and why.

11. Please list any siblings or other people living in the home. (Include ages and relationship to child.)

12. Are there any other family or household issues you feel are important to share with us?

13. What school is your child currently attending?*

14. What grade is your child currently in?*

15. Does your child receive any special services in school currently? If so, please provide details.*

16. Does your child currently have an Individualized Education Plan (IEP) or 504 Accommodations in school? If so, briefly describe the supports currently provided.*

17. What are your child's academic strengths and weaknesses?*

18. What activities does your child currently participate in outside of school? Describe how the activities typically go.*

19. How often does your child have play dates or see children outside of school? Describe how these interactions go.*

20. What are typical triggers that make your child upset?*

21. What strategies have been successful to calm your child down when upset?

22. Do you intentionally use any incentives or positive reinforcement at home with your child (behavior charts, prizes, toys, money, food, TV or video game time, family time, etc.)? Do you feel like it has been effective in improving your child's behavior?

23. Do you intentionally use any negative consequences at home with your child (time-out, loss of privilege, removing attention)? Do you feel like it has been effective in improving your child's behavior?

24. Has your child engaged in any aggressive or unsafe behaviors, running away or destruction of property in the past six months? If so, please explain.*

25. Does your child have any difficulties with toileting, changing their clothes or eating during a typical school day?*

26. Is there anything else you would like to share that would help us better understand your child and their needs for the summer program?

If yes, who was the psychologist, social worker, or provider that gave them the diagnosis?

Please provide the name of your current or past mental health provider.*

28. Please describe your child's treatment history (what type of provider, how often were appointments, reason for treatment, was it helpful).*

29. Has your child ever been hospitalized for any psychiatric or medical reason? If so, please explain.*

30. Does your child currently have any serious medical or physical problems?*

31. Does your child have any allergies?*

32. Does your child have any major dietary restrictions?*

33. Does your child have any physical limitations that would prevent them from participating in a typical school day or sports activities?*

If yes, list name, dosage, and reason for taking.

Summer Application Fee

Price:

Total

Credit Card*

Card Details

Cardholder Name

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Summer Program

Child's Info

Parent 1 Info

Parent 2 Info

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