Dreams With Wings Youth Programming Application

Thank you for your interest in Dreams With Wings Youth

programs.

Please complete this form to begin the onboarding process as a prospective new client.

This form covers our year round Youth Programming (Children ages 2-6, Youth ages 7-13 and Teens ages 13-18, Young Adults 19-29).

Please type "N/A" for any answers that do not apply to your applicant. Once we have reviewed the application, we will schedule a short introductory call to discuss our program offerings and next steps.

Applicant Information

Applicant's first name

Applicant's last name

Address (Street, City, St)

County (e.g. Jefferson)

Applicant's T-Shirt Size

Caregiver Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Primary Phone Number

Primary Parent/Guardian Email

Would you like to add an additional Parent/Guardian?

Yes

Which program are you interested in applying for?

Children (2-6)

Youth (ages 7-13)

Tweens/Teens (13-18)

Teen/Young Adult (ages 18-29)

Will you be using Private Pay or Respite (Michelle P Waiver)?

Private Pay

Respite - Michelle P Waiver

Is the applicant on the Michelle P Waiver Waitlist, meaning you have applied for the waiver but have not yet been approved?

Yes, s/he IS on the waitlist

No, s/he is NOT on the waitlist

Medical Information

Applicant's Primary diagnoses:

Autism Spectrum Disorder/Developmental Disability

Down syndrome /Intellectual Disability

Does the applicant require hand-over-hand teaching?

Is the applicant on medication(s)?

Yes

Does the applicant have allergies?

Yes

Does the applicant carry an epi-pen?

Yes

How does the applicant learn visually, for example does s/he learn best when her/his sense of sight is engaged? Any details you can provide below will help us teach concepts using this learning style.

How does the applicant learn using auditory senses, for example does s/he learn best when her/his sense of hearing is engaged? Any details you can provide below will help us teach concepts using this learning style.

How does the applicant learn kinesthetically, for example does s/he learn best when her/his senses of touch, movement and motion are engaged? Any details you can provide below will help us teach concepts using this learning style.

Level of Independence/Support Needs

Given your applicant's skills and behaviors, what level of supervision does s/he require for most of the day? Please keep in mind how s/he might respond to new situations, new people, and transitioning from one activity to another.

Totally independently in all or almost all settings with only occasional supervision

Independently for short periods; functions in a group with 1 staff & several peers rest of the time

Generally functions in a group with 1 staff and 2-3 peers ; needs one to one for specific activities

Generally needs one to one supervision, but can function in group situations for some activities

Needs one to one supervision throughout the day

Needs more than one staff with him/her all day

Staff Preference (we cannot guarantee this preference will be given)

Applicant will do better with MALE staff

Applicant will do better with FEMALE staff

Applicant will do equally well with either a MALE or FEMALE staff member

Can the applicant ask for help?

Yes

Can the applicant communicate an illness or pain?

Yes

Which type of schedule works best for the applicant?

Verbal

Written

Photo/Graphic

Does not require a schedule

How do the applicant handle transitions? Please explain what types of transitions are difficult and techniques or reinforces to help her/him be successful.

What types of ambulation needs does the applicant have? If none, enter N/A.

Mealtime Assistance

Eats independently ; can open packaging independently

Eats independently ; may need assistance with opening

Will need assistance with eating and opening

Mealtime capabilites and support needs (check all that apply)

Does the applicant have any dietary needs or food allergies? (gluten free, no sugar, no pork, etc.) If none, enter N/A.

Toileting Assistance

Completely independently toilet trained

Independent in the bathroom ; may need reminders to go

Needs some assistance in the bathroom

Needs complete assistance / total supervision in the bathroom

Is not toilet trained at all (in diapers / training pants)

Needs help with feminine hygeine

Will use too much toilet paper / clogs the toilet

Needs reminders to wash hands

How does the applicant let you know that s/he needs to use the bathroom?

How often does the applicant need to use the bathroom?

Does the applicant have a behavior support plan in place? If so, we request a copy of that plan during the application process.

Yes

Please explain any behaviors checked above and common antecedent or triggers, resulting behavior, and consequences used at home, in therapy settings, and in the community.

Has the applicant been hospitalized for any of the reasons listed above?

Yes

Please list any other behaviors not mentioned above that we should be aware of so that we can provide the level of support needed. If none, enter N/A.

Do any of the above listed behaviors affect the applicant’s daily life?

Yes

Does the applicant have any obsessive or compulsive behaviors?

Yes

Has the individual had any involvement with law enforcement? (ex: school, home, or community setting)

Yes

Emotional Responses (check all that apply)

List things that scare or upset the applicant:

Please describe what helps to calm the applicant when he/she is sad, afraid, hurt, upset, etc.

How does the applicant react to pain?

Over reacts

Under reacts

Has a typical response to pain

Please note any other sensitivities and provide additional information.

Activity Levels (check all that apply)

Has typical attention span and level of activity for his/her age

Has a short attention span

Less active / needs motivation to participate

Overactive

Easily distracted by sights, sounds, people, etc.

Please describe how you manage her/his activity level and motivate her/him to participate.

Please list any undesirable activities for your applicant. Please be specific.

List any INDOOR activities that the applicant enjoys. (ex: painting, acting, board games, etc.)

Check the types of OUTDOOR activities that the applicant enjoys.

Ball (bowling, volleyball, ball toss, basketball, kick ball, soccer, etc.)

Water (swimming, slip & slide, water balloons, sprinkler, water relays, etc.)

Sensory (bubbles, free play with lights, sounds, smells, textures, balance beams/balls)

Exercising (sit-ups/push-ups, hiking, jump rope, riding bikes, stretching, trampoline, walking)

Group (duck-duck-goose, kickball, musical chairs, parachute games, relay races, volleyball, etc.)

Individual in a group setting (yoga, petting animals, dancing, building, aerobics, etc.)

Individual (corn hole, swinging, frisbee, hopscotch, playground, putt-putt, etc.)

Are there any occupational or physical therapy goals that the applicant is working towards that would be helpful to share with us?

Yes

What are the applicant's strengths?

What would you like for the applicant to get out of her/his experience at Dreams With Wings?

Is there anything else we should know about the applicant to make their experience a great one? The more we know about her/his likes/dislikes, skills, needs, behaviors, the better we can serve her/him.

How did you hear about Dreams With Wings?

Internet Search

Word of mouth

Referral from case manager

Referral from another organization (ex: FEAT, Council on Developmental Disabilities, etc.)

Social Media (Instagram, Facebook)

Other

Which programs are you interested in learning more about for applicant?

Information about Big & Small (ages 2-6)

Make, Move, Play program (ages 7-13)

Arts Programs (ages 12-16)

Creative Arts and Movement (ages 13-18, 19-29)

Drama skill building workshops, showcases, or classes with a sharing performance (ages 13-18, 19-29)

Community - Based Social skills groups (ages 14-18, 19- 29)

Dreams With Wings Youth Programming Application

Applicant Information

Caregiver Information

Program Choices

Payment Options

Medical Information

Learning Styles

Level of Independence/Support Needs