SNAP-A Program Interest Form Home | SNAP-A Program Interest Form Participant InformationParticipant First Name:*Participant Last Name:*Date of Birth (DD/MM/YYYY):*Age:*School (if applicable)School Board (if applicable)Have you previously participated in a group or a group sample session at Kinark?* Yes No If you have participated in a group at Kinark, please let us know the name(s) of the group:Are you currently receiving any other services at Kinark?* Yes No If 'Yes', please specify:*Contact InformationParent/Caregiver First Name:*Parent/Caregiver Last Name*Parent/Caregiver Email*Parent/Caregiver Phone Number:*Preferred Contact Method*EmailPhoneAddress*If you would like to include other contact information (e.g., another individual/caregiver) Please list their full name, relationship to the participant, contact information, and any other relevant details:Form completed by:*Participant ProfileTell us more about your child.Communication (please select one):* Speaks fluently in full sentences and can discuss events that happen in the past or future Speaks in full sentences, but may need support with extended discussions or reciprocal conversations Speaks in single, two or three word phrases Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device) Has no formal mode of communication (e.g., cries, pulls, points, pushes) Independence and Attention (please select one):* Can follow along with a group independently for 45 to 90 minutes (with breaks) May need some additional parent/adult prompting and/or modeling Will require one-to-one support to attend and/or participate If one-to-one support is required, please describe what the support would be for:*The SNAP-A program was designed to help children build emotion regulation, self-control, and social problem-solving skills. Does your child struggle with the following behaviours?*Select all that apply Has explosive outbursts Cries and stays angry for 5 minutes or longer Has extreme or intense emotional reactions Hard to calm him/her down when he/she is mad or upset Reactions are so intense that he/she has had to be removed from an activity or place Easily triggered/upset (you have to walk on eggshells around him/her) Other Where are these behaviours observed? (ie: at home only, at school only, in the community only, at both home and school, etc...)*If "Other", please describe:*The SNAP-A program will be group-based. Does your child engage in disruptive behaviours that might interfere with their ability to participate in a group (e.g., physical or verbal aggression, self-injury, property destruction, flight risk)?* Yes No If "Yes", please describe:*Please list any health conditions that may interfere with group participation (e.g., seizure disorder, anaphylaxis, anxiety, depression):What are some of your child’s topics of interest or preferred activities?If it is determined that the SNAP-A program is not the best fit for your child, would you be open to being contacted about Kinark's Applied Behaviour Analysis (ABA) Groups or other available services?*Please note: Some services may have associated fees Yes No Please share any additional information/comments/questions that you may have here:Acknowledgement* I understand that by submitting this form, I am expressing interest in being considered for a program. Completion of this form does not guarantee enrollment; selection will be based on availability and suitability.CAPTCHA
