Birthday*

Does individual have a ISP?*

Does individual have a BSP? *

Are you seeking full time or part time enrollment? (Be aware that part time spaces are extremely limited and could impact time on wait list.)*

Does the individual have any criminal history? *

Is the individual a registered sex offender? *

Can the individual feed themselves? *

Will the individual and/or their caregivers be able to send a lunch with the individual each day of program? (This is required.)*

Does the individual maintain control of their urinary functions and bowel movements?*

For Physical Aggression, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Verbal Aggression, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Property Destruction, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Eloping/Running Away, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Inappropriate Sexual Touching, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Stealing, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

For Self-Injurious Behavior, please select the frequency rating that you feel most accurately reflects the individual:*

Is this behavior predictable?*

Please select activities your individual enjoys: