Sibling Support Groups Interest Form Home | Sibling Support Groups Interest Form Information Collection Notice: This intake form is used to determine suitability of service and prepare for our initial contact with you. Interest FormConsent*By completing this form, you certify that you are the primary caregiver of the child/youth for whom this form is being completed. 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 Consultation’ form. I understand Group FormatPlease specify the group for which you are indicating interest:* In-Person at Markham Virtual Either Parent/Caregiver InformationName:* First Name Last Name Email* Phone*Preferred Contact Method* Email Phone Address* Street Address City Province Postal Code Information of Child/Youth with Autism (not the participant in the group)Name* First Name Last Name Date of Birth (DD/MM/YYYY)* DD slash MM slash YYYY AddressPlease complete only if primary residence if different from the parent's address above. Street Address City Province Postal Code Registered with the OAP?* Yes No Information of the Sibling (Participant in support group)Name:* First Name Last Name Age:*Email (if applicable):*Write N/A if not applicable Phone Number (if applicable):*Write N/A if not applicablePreferred Contact Method:* Email Phone Does the participating sibling have a diagnosis themselves that may impact their participation?* Yes No If 'Yes', please specify:Has this sibling participated in a sibling group with Kinark before?* Yes No If “Yes”, please specify what they liked about the group:What is the participating sibling’s level of independence (please select one that best describes your child):* Completes tasks/routines that is typical of their age Needs additional support from parents/caregivers to complete daily living tasks Requires one-to-one support to complete most daily tasks Does the participating sibling exhibit any behaviours that may interfere with their participation (please select all that apply):* Aggression Self-injury Property destruction Elopement Other (please specify below) Not applicable Please describeDoes the participating sibling have any health or medical conditions that may interfere their participation?* Yes No If 'Yes', please specify:Participation RequirementsPlease note that we request only the siblings of the child/youth with autism join these support groups without other family members.Please confirm that the participating sibling is able to (select all that apply)* Attend an orientation session for an overview of the group and to review group expectations Attend all 5 weekly sessions and participate in discussions with the facilitators and other siblings as they feel comfortable Additional InformationHow did you learn about this service? (Please check all that apply):* AccessOAP York Simcoe Autism Network (YSAN) Kinark Autism Services Website Kinark Staff Marketing materials (e.g., brochure, flyer, poster) Kinark Service Guide Email Newsletter Google Search Kinark Open House Community Event Another Community Agency / Organization Physician or other Healthcare Professional School Board Social Media (e.g., Facebook, Instagram) Personal Contacts (e.g., Friends, Family Members) Conferences Other Do you want to be added to our mailing list to receive information about our programs and services?* Yes No CAPTCHA