Social Skills Group Application

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Social Skills Group Application

7/24/15

Dear Parents and Caregivers,

Effective October 1, 2015, the US Department of Health and Human Services is mandating that all

providers, facilities and hospitals transition to a new medical coding system, the International

Classification of Disease, 10

th

revision (ICD-10).

What this means is your child’s diagnosis will have a different code connected to it. This is the code that

we bill Medicaid for to pay for your child’s group participation (if you qualify for Medicaid or the Katie

Beckett Waiver). We also use the information to see the make up of our groups.

We will need to get your pediatrician, primary care doctor or a clinician at your CEDARR Center to tell us

the new medical code.

You don’t need to do a re-evaluation!

We need a clinician to write down the

ICD-10 Code that matches your child’s diagnosis. Only the codes are changing.

Please have your child’s physician fax the completed form below to the Autism Project so that we can

provide Medicaid with the required information.

Thank you for your cooperation. Please contact us with any questions or concerns.

Joanne G. Quinn

Executive Director

P 401-785-2666 F 401-785-2272

Date: ________________________

Child’s Name: ______________________________________________________________

ICD-10 Diagnosis: ____________________________________________________________

Physician’s Signature: ________________________________________________________

Dear Physicians and Clinicians,

We are changing our codes to ICD-10. Please list your patient’s diagnosis and the relevant ICD-10 Codes.

We can then enter the accurate medical diagnosis into our Medicaid Database. Please fax the form to

our offices by September 30, 2015 attn: Group Coordinator.

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Social Skills Group Application

www.theautismproject.org ● The Autism Project, 1516 Atwood Avenue, Johnston, RI 02919 ● P (401)785-2666 ● F (401)785-2272

APPLICATION

DEADLINE:

A

UGUST

28,

2015

PERSONAL INFORMATION

Participant’s Name

:

DOB:

Grade:

Age:

Gender:

Address:

City:

State: Zip:

ICD-10 Diagnosis: Autistic Disorder Asperger’s Syndrome Other Pervasive Developmental Disorder Other:

Please FAX the Physician’s Form to 785-2272 to confirm your child’s diagnosis. Your child does not have to have a diagnosis of ASD to participate in groups. We need confirmation of the new ICD-10 Code for his/her diagnosis strictly for billing purposes. (See attached Physician’s Form)

PARENT

/

LEGAL GUARDIAN INFORMATION

Parent #1 Name

:

Relationship:

Address:

City:

State: Zip:

E-mail:

Home#:

Cell#:

Parent #2 Name

:

Relationship:

Address:

City:

State: Zip:

E-mail:

Home#:

Cell#:

Please indicate the primary contact person

Parent#1

Parent#2

Both

WHAT TYPES OF GROUPS WOULD YOU LIKE YOUR CHILD TO PARTICIPATE IN

?

Foundational Group Skills

Move & Groove Leaps & Bounds

Arts

Creative Expressions (art) *additional materials fee*

Curtain Call (theater) In Harmony (music)

Recreational/Leisure Groups Game On! Karate

Game On! Basketball

*Game On! Swim- New Group!* Middle/High School & Young Adult Club Jr.

Club

Please list any group(s) your child has previously attended at The Autism Project:

How many groups would you like your child to attend weekly?

What days will your child be available to attend groups?

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays

What do you hope your child will gain from his/her experience here?

Office Use Only

Client#_______________ New Ret. M SP

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Social Skills Group Application

Participant Name:

EMERGENCY & MEDICAL INFORMATION:

Please attach a recent photograph of your child

Emergency Contact #1 Name:

Relationship:

Home#:

Cell#:

Emergency Contact #2 Name:

Relationship:

Home#:

Cell#:

Physician’s Name:

Phone#:

Current Medications:

Allergies:

Food Restrictions:

Seizures (yes/no):

Other:

In case of emergency, I understand that every effort will be made to contact me or the contact people listed above. If I cannot be reached, I understand that staff will use a standard 911 protocol and have my child taken to the nearest hospital.

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Social Skills Group Application

Participant Name:

Please help up get to know your child by providing the following information

SUPPORT NETWORK

Is your child receiving any of the following services? (Please include agency name):

SCHOOL INFORMATION

School name and district:

What kind of school does your child attend?

Public Home School Private

Does your child have an Individual Education Plan?

(IEP)

Yes No

What type of classroom is your child in?

Mainstream

Inclusion Self-contained Other:

Does your child have a 1:1 classroom assistant?

Yes No

Has your child had experience (past or present) with any of the following:

Visual Schedules Chewing Gum

First/Then Boards Headphones Social Stories Relaxation Protocols

Work Systems Weighted Materials Other:

CEDARR: HBTS:

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Social Skills Group Application

Participant Name:

What are your child’s favorite activities or interests? (movies, characters, foods, games, music, etc)

Does your child have any specific dislikes? (sounds, smells, touch, movement, foods, etc)

SOCIAL EMOTIONAL

(

please check all that apply to your child

)

My child has difficulty:

Engaging in play or leisure activities with peers Taking turns/sharing

Maintaining personal space of self/others

Commenting on the environment to others (describes, labels, names) Engaging in activities that are not highly preferred

Recognizing how his/her behavior effects others Identifying problems/conflict

Identifying solutions and potential consequences to problems/conflict Recognizing his/her own emotions

Recognizing other’s emotions

Utilizing appropriate coping strategies when upset

COMMUNICATION LEVEL

(

)

My child:

Is verbal Is nonverbal

Uses an augmentative communication system/device (please specify): Follows verbal/nonverbal directions

Utilizes visual supports to follow directions Indicates his/her likes and dislikes

Makes requests for his/her basic wants and needs

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Social Skills Group Application

Participant Name:

BEHAVIOR

(

)

My child may:

Run away

Act aggressively towards self/others: Shut down/withdraw

Be non compliant

Inappropriately touch self/others: Is self injurious

Other:

SENSORY

(

)

My child:

Avoids or seeks touch from others (please circle which)

Avoids or seeks messy play such as play do, glue and paint (please circle which) Plays rough in play/leisure activities

Avoids participation in sports or active games Craves or avoids movement (please circle which)

Seems to be in constant motion (loves spinning, swinging, being upside down) Cannot process or tolerate extremes of intensity such as color, light etc. Is over or under sensitive to sounds (please circle which)

Eats non-edible items Dislikes strong smells/tastes

ACTIVITIES OF DAILY LIVING

(

ADLS

)

(

)

My child is NOT yet independent in the following areas:

Dressing/Bathing Eating Ambulating (walking) Toileting Hygiene Shopping Daily Chores Money Management Food Preparation/Meds Telephone/Transportation

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Social Skills Group Application

Participant Name:

PERMISSION

TO

PHOTOGRAPH

The Autism Project has an OPEN PICTURES POLICY. Children attending groups may have their pictures and/or video taken. Pictures/videos may be used for training purposes, program development, marketing and including but not limited to, newspaper articles, television promotions, brochures, social media (Facebook, YouTube, etc.) and other Autism Project and our funders’ marketing vehicles (such as annual reports, board meeting materials, website and Facebook.)

I understand that by signing below I agree to the open pictures policy.

Signature of Parent/Guardian: Date: Printed name of Parent/Guardian:

PERMISSION

FOR

RESTRICITVE

PROCEDURES

The Autism Project uses evidenced-based strategies that are designed to establish a supportive and safe environment that will prevent your child from having behavioral difficulties. There may be rare occasions when the physical safety of your child, other participants, and staff is at risk. When this type of incident occurs it may be necessary to physically hold your child to prevent harm, and to help her/him feel safe. Staff will only use approved therapeutic holds/restraints for which they have been trained. The hold is only maintained for as long as it takes for your child to begin to regain emotional and physical control so that s/he can move to a quieter area until they are able to rejoin the group. These procedures are carried out in a calming, supportive, and non-punitive manner. You will be notified when you pick up your child of the intervention so that you can assist staff in processing the incident and supporting your child.

I understand that the above procedures will be implemented only for the purpose of safety and in accordance with the stated guidelines.

Signature of parent/guardian: Date: Printed name of parent/guardian:

PERMISSION

TO

PICK

UP

CHILD

Please complete the following information in the event that someone other than yourself may pick up your child from a social skills group. Group staff will refer to this information at the time of group dismissal.

 You must notify group staff in advance of who will be picking up your child if he or she is not on the list.

 We will ask that person to present his/her identification before releasing your child to him/her.

 It will be the responsibility of the primary caregiver to update this list as needed.

 All individuals picking up a child are required to come into the building and to sign-out with a staff person before leaving.

Name Relationship Phone #

Signature of Parent/Guardian: Date:

Printed Names of Both Parents/Guardians:

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Social Skills Group Application

Participant Name:

Agreement for Attendance and Payment

Authorization for Payment

The Autism Project provides social skills groups and specialized treatment for children through an established fee structure. The fee is $25 per week.This fee will be prorated in the event that your child is placed in a group after the start date. Additional fees (such as materials costs etc.) may apply depending on the specific group. You will be notified at the time of placement.

We will pursue reimbursement for services through one of the following sources, as designated by you: Medicaid (child must be eligible through RIteCare, Katie Beckett, SSI, or adoption subsidy)

Self-pay

PLEASE NOTE: Payment is due 1 week prior to the start of the session; applications for scholarships are

available

Cancellations

Our program sustainability relies heavily on attendance. Cancellations must be made within 24 hours prior to a scheduled group. To report an absence, please call the office at 785-2666 with the child’s name, group name and date. After two absences, program participation will be reviewed and may result in loss of placement for that session.

Application Process

Parents/Caregivers must complete a full group application each year. Returning applicants are not guaranteed placement.

Placement

Our program coordinators base placement decisions on a variety of factors including age, individual needs, abilities and interests. You will be contacted about your child’s placement in group prior to the start of the session. Whenever possible, we will try to accommodate your group preferences.

I understand the above policies and procedures and authorize The Autism Project to bill Medicaid, me, or my insurance company as designated for payment. I also understand that if my child loses his/her Medicaid I will be responsible for paying my child’s group fees.

Signature of parent/guardian: Date: Printed name of parent/guardian:

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Social Skills Group Application

Date:

Dear Participant,

This is a survey we need you to complete once every year in order to report statistical and demographic

information for a United Way grant that supports this program and to fulfill data requirements for future

grant opportunities. Please take a few minutes to fill out the survey below. No names are required and

all information will be kept strictly confidential. Thank You!

Direct Service Programs Demographic Survey

Participant’s Information

Sex of participant

Male

Female

Participant’s Age:

Participant’s Primary Language

English

Spanish

Portuguese

Non-verbal

Primary Diagnosis

Autism

Asperger Syndrome

Childhood Disintegrative Disorder

High Functioning Autism

Fragile X

Retts Syndrome

PDD-NOS

Non-Verbal Learning Disorder

Family’s Information

Number of people living in the household

0-20,000

10,000-25,000

26,000-50,000

51,000+

Race & Ethnicity

African

African American/Black

Asian

Asian American/Pacific Islander

Cape Verdean

Caribbean

Caucasian/White (non-Hispanic)

Hispanic/Latino

Native American

Portuguese

Multi-Racial/Multi-Ethnic

Other (please specify):

Information Not Available

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Social Skills Group Application

Payment Information

Participant Name:

Social Security #:

(must be included even for self-pay)

Parent Name:

Address:

City:

State: Zip:

CEDARR Center:

Method of Payment for $15 Application Fee

(due for all applicants; non-refundable)

Check

Money Order

PayPal

Amount enclosed:

Credit Card #

Exp. Date:

Cardholder’s Name:

Cardholder’s Billing Address:

Method of Payment for Program Fee (

$25 per week)

RI Medicaid

(RIteCare, Katie Beckett, Adoption Subsidy, SSI)

(

please include copy of card)

Self-pay

Check

Money Order

PayPal

Visa/MasterCard/Discover #

Exp. Date:

Cardholder’s Name:

Cardholder’s Billing Address:

Scholarship: if you are in need of financial assistance, please complete an application for a scholarship

and submit at least 2 weeks prior to the start of groups.

I authorize The Autism Project to process my payment as indicated above.

Parent/Guardian Signature: Date:

FOR OFFICE USE ONLY

Payment Received: / / $_____ Initials:_____ Medicaid Eligible: yes no Scholarship Application Received: ___/___/___ Amount Awarded: _________ for ___ groups