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.
Does the applicant attend school, day program, have supported employment, is homeschooled etc.?
Would you like to add an additional Parent/Guardian?
Which program are you interested in applying for?
Will you be using Private Pay or 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?
Applicant's Primary diagnoses:
Applicant's additional diagnoses, please check all that apply.
Is the applicant on medication(s)?
Does the applicant have allergies?
Does the applicant carry an epi-pen?
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.
Staff Preference (we cannot guarantee this preference will be given)
How does the applicant communicate what s/he wants and needs?
How does the applicant understand what is said to her/him?
Can the applicant ask for help?
Can the applicant communicate an illness or pain?
Which type of schedule works best for the applicant?
Mealtime capabilites and support needs (check all that apply)
Does the applicant have a behavior support plan in place? If so, we request a copy of that plan during the application process.
Please check any behaviors that have happened in the past year. This information helps us understand the level of support needed for her/him to be successful in a group setting.
Has the applicant been hospitalized for any of the reasons listed above?
Do any of the above listed behaviors affect the applicant’s daily life?
Does the applicant have any obsessive or compulsive behaviors?
Has the individual had any involvement with law enforcement? (ex: school, home, or community setting)
Emotional Responses (check all that apply)
Please check the following sensory inputs that your applicant might OVER REACT to.
How does the applicant react to pain?
Describe manner of reinforcement
Activity Levels (check all that apply)
Are there any occupational or physical therapy goals that the applicant is working towards that would be helpful to share with us?
How did you hear about Dreams With Wings?
Which programs are you interested in learning more about for applicant?
