Kinark Group Interest Form

Information Collection Notice: This intake form is used to determine suitability of service and prepare for our initial contact with you.

Kinark Group Interest Form

I am interested in:*
- March Break Groups
- Reading Week Groups (Ages 18+)
- Spring Sessions (April – June)
Please select the group(s) you are interested in:*
- Ready, Set, Play!
- Explorer Club
- Emotions and Me
- Children’s Friendship Training
- Friendship Crew
- AIM
- PEERS®
- Dungeons & Dragons
- Career Connections
- Friendship Crew Boot Camp
- Bully Proofing Crew Boot Camp
- PEERS® Friendship Boot Camp
- PEERS® Bully Proofing Boot Camp
- PEERS® Dating Boot Camp
- PEERS® Dating (18+)
- PEERS® Friendship (18+)
- Not sure – please find the best group for me!
Please select the delivery format you are interested in:*
- Virtual (online)
- In-person
- Both virtual and in-person
If you are interested in in-person groups, please select the location(s) you are interested in:*
- Select All
- Richmond Hill
- Barrie
- Oshawa
- Markham
- N/A – I am not interested in in-person groups
Don’t see a suitable group? Let us know what you’re looking for here:
Participant Information
Participant First Name:*
Participant Last Name:*
Date of Birth (DD/MM/YYYY):*
Age:*
Siblings:*
- Yes
- No
If "Yes", please specify the sibling age(s):
School
School Board
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:
Have you previously participated in a group or a group sample session at Kinark?*
- No
- Yes – group sample session only
- Yes – I have participated in a group at Kinark
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 Information
Who should we contact with information about the group(s) and next steps?:*
- Participant
- Parent/Caregiver
Parent/Caregiver First Name:
Parent/Caregiver Last Name
Email*
Phone Number:*
Preferred Contact Method*
Address*
If another individual/caregiver may be involved, please list their full name, relationship to the participant, contact information, and any other relevant details:
Participant Profile
I am/ my child or teen is (please select all that apply):*
- motivated to participate in a group
- motivated to interact with peers (vs. avoiding social interactions)
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 two or three word phrases
- Speaks in single words
- 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 60 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:*
Some behaviours may make it challenging to participate in a group, or may be disruptive to group participation (e.g., physical or verbal aggression, self-injury, property destruction). Do you/your child have any behaviours that may hinder group learning?*
- Yes
- No
If yes, please describe what the behaviours may look like:*
Where are these behaviours observed? (ie: at home only, at school only, in the community only, at both home and school, etc…)*
Please list any health conditions that may interfere with group participation (e.g., seizure disorder, anaphylaxis, anxiety, depression):
What are some of your/your child or teen’s topics of interest or preferred activities?
Do you have any suggestions to improve your/your child or teen’s success with a group program?
Please share any additional information/comments/questions that you may have here:
Parent/Caregiver Participation
Please complete this section if a social coach/parent/caregiver is involved.
I am able to (please select all that apply):
- attend a parent orientation session for an overview of the group and to review group expectations
- attend ongoing parent education sessions and help my child/teen with homework activities to practice the skills learned
Technology Requirements
Do you have adequate internet connectivity (i.e., high-speed internet with sufficient bandwidth) and access to appropriate technology (e.g., a computer/laptop/tablet) which supports video conferencing (i.e., have a microphone, speakers, and a webcam)?*
- Yes
- No
Would you be using a password-protected, secure internet connection to join the group (vs. public or unsecured Wi-Fi)?*
- Yes
- No
How did you hear about us?*
- Informal networking (e.g., friends, family, support group)
- Physician or other medical professional
- Social media (e.g., Facebook, Twitter)
- Community agency or organization
- Google or other search engine
- Ministry website/letter
- Brochure/flyer/poster
- Online advertisement
- Kinark newsletter
Do you want to be added to our mailing list to receive information about our programs and services?*
- Yes
- No
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Kinark Group Interest Form

Kinark Group Interest Form

Participant Information

Contact Information

Participant Profile

Parent/Caregiver Participation

Technology Requirements

Stay Connected

Our Locations

Barrie ABA Centre

Etobicoke ABA Centre

Markham ABA Centre

Oak Ridges ABA Centre

Oshawa ABA Centre

Thornhill ABA Centre

Helping children and youth with complex needs achieve better outcomes.

This site uses cookies

Kinark Group Interest Form

Participant Information

Contact Information

Participant Profile

Parent/Caregiver Participation

Technology Requirements

Stay Connected

Our Locations

Barrie ABA Centre

Etobicoke ABA Centre

Markham ABA Centre

Oak Ridges ABA Centre

Oshawa ABA Centre

Thornhill ABA Centre

Helping children and youth with complex needs achieve better outcom﻿es.

This site uses cookies

Helping children and youth with complex needs achieve better outcomes.