Kinark Group Readiness Interest Form

Information Collection Notice: This intake form is used to determine clinician assignment, suitability of service, and prepare for our initial contact with you. The information collected will be stored in your child’s confidential client record and will only be accessible by those actively involved with your service.

Parent and Caregiver Information
Parent First Name:*
Parent Last Name:*
Parent Email:*
Parent Phone Number:*
Preferred contact method:*
- Phone
- Email
Parent Address:*
If another caregiver (other than the parent completing the screening) may be involved, what is their full name, relationship to the child, contact information, and any other relevant details?
Consent
By completing this form, you certify that you are the primary caregiver of the child/youth which this form is being completed for. If you are not the primary caregiver, you confirm to have consent from the primary caregiver to complete this form. If you are not the primary caregiver or do not have consent from the primary caregiver and are looking to inquire about our services, please complete our 'Request a Free Consultation' form.
Child Information
Child First Name:*
Child Last Name:*
Date of Birth (DD/MM/YYYY):*
Age:*
Siblings:*
- Yes
- No
If "Yes", please specify the sibling age(s):
Current School:*
School Board:*
Grade:*
Placement Type:*
- Mainstream (no support)
- Mainstream (with support)
- Part-time learning centre
- Community/county - Autism Spectrum Disorder (ASD)
- Community/county - developmental disabilities
- Other
If "Other", please specify:
Office and Technology Requirements
Will you be available to support your child for the duration of the session each week?*
- Yes
- No
Do you have adequate internet connectivity for video conferencing (i.e. high-speed internet with sufficient bandwidth)?*
- Yes
- No
Would you be using a password-protected, secure internet connection to join the group (vs. public or unsecured Wi-Fi)?*
- Yes
- No
Do you have access to appropriate technology (i.e. device) to join the group (e.g. a computer/laptop/tablet)?*
- Yes
- No
Can your device support video conferencing (i.e. have a microphone, speakers, and a webcam)?*
- Yes
- No
Do you have access to earphone/headphones if needed?*
- Yes
- No
Are you comfortable using the internet/your devices, and feel confident in your ability to join the group (with an orientation and minimal support)?*
- Yes
- No
Do you have a reasonably quiet and private area in your home to join the group?*
- Yes
- No
Caregiver Requirements
Are you willing/able to complete an assessment form online for the facilitators so they are aware of your child's current set of skills and areas of need?*
- Yes
- No
Are you able to attend two mandatory parent education sessions prior to the start date of the group to review ABA and group readiness skills?*
- Yes
- No
Are you willing/able to sit beside your child during each session (for the entire duration of the session) to prompt or redirect as needed?*
- Yes
- No
Are you willing/able to collect data during the sessions, as well as complete homework and activities out of the sessions?*
- Yes
- No
Are you willing/able to maintain correspondence with the group facilitators (via email or phone) to acknowledge receipt of materials sent, or discuss any potential concerns that you or the facilitators may have?*
- Yes
- No
Please provide any additional information relevant to this section:
Child Requirements and Pre-requisite Skills
Is your child able to speak in full sentences fluently (vs. using single words / simple phrases with 2-3 words / sign language / picture exchange communication system (PECS) / another speech generated device)?*
- Yes
- No
Is your child able to respond to simple instructions?*
- Yes
- No
Is your child able to attend toward the screen for 15 minutes at a time?*
- Yes
- No
Can your child participate in a 60 minute engaging session that includes multiple short activities (with brief breaks) independently or with minimal parent support?*
- Yes
- No
Is your child motivated to participate in a group and/or interact with his/her peers (vs. avoiding social interactions)?*
- Yes
- No
Can your child acknowledge or respond to praise delivered by a facilitator during a video session?*
- Yes
- No
Can your child respond to requests to imitate (i.e., clapping hands, standing up, shaking head)?*
- Yes
- No
Can your child look at the screen if they hear their name being called (by a peer or a facilitator) during a video session?*
- Yes
- No
Can your child respond chorally in a group setting (i.e., everyone say ‘hi’, or everyone stand up)?*
- Yes
- No
Can your child come to the work area when asked by a facilitator during a video session (or when asked by a school teacher during online learning)?*
- Yes
- No
Does your child engage in challenging behaviours that you feel may be a barrier to his/her participation, or be disruptive to the group?*
- Yes
- No
Please provide any additional information relevant to this section:
Considerations for Group Learning
Has your child participated in online learning previously (e.g. for school)?*
- Yes
- No
If "Yes", please describe:
Has your child participated in group-based services previously?*
- Yes
- No
If "Yes", was it in-person or virtual?
If "Yes", who provided the service?
If "Yes", what was the nature of the group?
If "Yes", what were the objectives/goals?
If "Yes", in your opinion, were the goals met?
If "Yes", how was your experience (what did you like and what could have been done differently)?
What are your suggestions (tips and tricks) to have your child engage with his peers and participate during this group?*
Are there any potential triggers for your child that we should be aware of for the purposes of this group (e.g. being told ‘No or ‘Wait’, significant dislike of certain items/topics, notable fears, etc.)?*
What are some limitations you have experienced with online learning in the past year for your child?*
In your opinion, your child would benefit from additional instruction / learning opportunities in which of the following domains (during this readiness group)?*
- Online skills (e.g., showing the ability to interface with virtual platforms and tolerance to learning online)
- Listening and following one-step instructions (e.g., responding appropriately to instructions given by facilitators and peers)
- Imitation (e.g., responding to verbal or physical requests to copy words or actions)
- Greetings (e.g., initiating and responding to greetings)
- Teamwork (e.g. taking turns, cooperating within a group)
- Perspective Taking (e.g. recognizing how others are feeling and responding appropriately)
- Communication (e.g., initiating, maintaining, ending conversations, making comments, staying on topic, changing the topic)
- Self-regulation and remaining on task (e.g., responding appropriately when in a disagreement with a friend)
- Group Learning Skills (e.g., attending to group activities, responding together with a group, following multiple instructions in a group)
Are there any specific readiness goal(s) you have for your child that you would like to see improve? Are there any areas that we can support you in facilitating?*
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Kinark Group Readiness Interest Form

Parent and Caregiver Information

Child Information

Office and Technology Requirements

Caregiver Requirements

Child Requirements and Pre-requisite Skills

Considerations for Group Learning

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