Dreams With Wings Youth Programming Application
Please complete this form to begin the on boarding process as a prospective new client. This form covers our year round Youth Programming (Youth ages 8-13 and Teen/Young Adult ages 13-29). Please type "N/A" for any answers that do not apply to your applicant. Once we have reviewed the application, we will schedule a short introductory call to discuss our program offerings and next steps.
Applicant's first name
Applicant's last name
Applicant's DOB
Applicant's age
Applicant's Sex
Select an option
Female
Male
Prefer not to disclose
Applicant's Height
Applicant's Weight
Address (Street, City, St)
Zip Code
County
Applicant's T-Shirt Size
Select applicant's t-shirt size
Youth XS
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2XL
Adult 3XL
Adult 4XL
Adult 5XL
Adult 6XL
Does the applicant attend school, day program, have supported employment, is homeschooled etc.? If so, what is the name of the school, day program, employer, etc.?
Parent/Guardian's First Name
Parent/Guardian's Last Name
Primary Phone Number
Primary Parent/Guardian Email
Primary Parent/Guardian Employer
Secondary Parent/Guardian First Name
Secondary Parent/Guardian Last Name
Secondary Parent/Guardian Phone Number
Secondary Parent/Guardian Email
Which program are you interested in applying for?
Youth (ages 8-13)
Teen/Young Adult (ages 13-29)
Will you be using Private Pay or Respite (Michelle P Waiver)?
Private Pay
Respite - Michelle P Waiver
Is the applicant on the Michelle P Waiver Waitlist, meaning you have applied for the waiver but have not yet been approved?
Yes, s/he IS on the waitlist
No, s/he is NOT on the waitlist
If using Respite (Michelle P Waiver), what is your case manager's name:
Case manager's Phone Number:
Case manager's Email:
Case manager's Agency Name:
For applicants 18+ years, has the applicant been adjudicated incompetent in court with an appointed legal guardian? If yes, who is their legal guardian? If no or under 18, type "no".
Applicant's Primary diagnoses:
Autism Spectrum Disorder/Developmental Disability
Down syndrome /Intellectual Disability
Applicant's additional diagnoses, please check all that apply.
Level 1 Autism
Communication Disorder
Cerebal Palsy
Intellectual Disability
Visual Impaiment
Hearing Impairment
Seizure Disorder (in the past 3 years)
Mental Health Diagnosis
Diabetes
Fragile X
ADHD
ADD (Attention Deficit Disorder)
ODD (Oppositional Defiant Disorder)
Expressive/Receptive Language Disorder
Dyslexia
Apraxia
Dyscalculia
Hydrocephalus
Other, please specify below.
Please specify any additional diagnoses that were not listed above.
Has the applicant been hospitalized for any of the reasons listed above? If yes, please describe.
Is the applicant on medication(s)? If yes, please note the name(s), purpose(s), and how often they take them. If none, enter N/A.
Applicant's allergies (please note severity as well). If none, enter N/A.
Does the applicant carry an epi-pen?
Yes
No
Physician's Name
Physician's Phone Number
How does the applicant learn visually, for example does s/he learn best when her/his sense of sight is engaged? Any details you can provide below will help us teach concepts using this learning style.
How does the applicant learn using auditory senses, for example does s/he learn best when her/his sense of hearing is engaged? Any details you can provide below will help us teach concepts using this learning style.
How does the applicant learn kinesthetically, for example does s/he learn best when her/his senses of touch, movement and motion are engaged? Any details you can provide below will help us teach concepts using this learning style.
Given your applicant's skills and behaviors, what level of supervision does s/he require for most of the day? Please keep in mind how s/he might respond to new situations, new people, and transitioning from one activity to another.
Totally independently in all or almost all settings with only occasional supervision
Independently for short periods; functions in a group with 1 staff & several peers rest of the time
Generally functions in a group with 1 staff and 2-3 peers ; needs one to one for specific activities
Generally needs one to one supervision, but can function in group situations for some activities
Needs one to one supervision throughout the day
Needs more than one staff with him/her all day
Staff Preference (we cannot guarantee this preference will be given)
Applicant will do better with MALE staff
Applicant will do better with FEMALE staff
Applicant will do equally well with either a MALE or FEMALE staff member
How does the applicant communicate what s/he wants and needs?
Uses complete sentences
Uses 2-3 word phrases
Uses single words
Uses vocalizations and sounds
Uses sign language
Uses gestures such as pointing
Uses objects to communicate
Takes you to what they want
Cries/whines
Uses pictures
Uses word cards
Writes to communicate
Uses adaptive speech, communication device, or other technology
How does the applicant understand what is said to her/him?
Understands complete sentences
Understands 2-3 word phrases
Understands single words
Understands sign language
Understands gestures such as pointing
Understands objects to communicate
Understands pictures
Understands word cards
Understands writing
Understands through use of adaptive speech, communication device, or other technology
Can the applicant ask for help?
Yes
No
Can the applicant communicate an illness or pain?
Yes
No
Which type of schedule works best for the applicant?
Verbal
Written
Photo/Graphic
Does not require a schedule
How do the applicant handle transitions? Please explain what types of transitions are difficult and techniques or reinforces to help her/him be successful.
What types of ambulation needs does the applicant have? If none, enter N/A.
Mealtime Assistance
Eats independently ; can open packaging independently
Eats independently ; may need assistance with opening
Will need assistance with eating and opening
Mealtime capabilites and support needs (check all that apply)
Can use all utensils
Cannot use fork
Cannot use spoon
Cannot use knife
Drinks from a cup unassisted
Chews and swallows food with no problems
Choking risk
Has good table manners
Has inappropriate table manners (throws food, etc.)
Does the applicant have any dietary needs or food allergies? (gluten free, no sugar, no pork, etc.) If none, enter N/A.
Toileting Assistance
Completely independently toilet trained
Independent in the bathroom ; may need reminders to go
Needs some assistance in the bathroom
Needs complete assistance / total supervision in the bathroom
Is not toilet trained at all (in diapers / training pants)
Needs help with feminine hygeine
Will use too much toilet paper / clogs the toilet
Needs reminders to wash hands
How does the applicant let you know that s/he needs to use the bathroom?
How often does the applicant need to use the bathroom?
Please check any behaviors that have happened in the past year. This information helps us understand the level of support needed for her/him to be successful in a group setting.
Scratches, pinches, bites, or hits self
Bangs own head
Scratches, pinches, bites, or hits others
Grabs other people
Touches others inappropriately
Throws things
Gets into personal belongings
Runs/wanders away
Climbs on furniture
Uses inappropriate language
Spits on others
Dumps liquids
Strips own clothing
Exposes self in public
Masturbates inappropriately
Is not trustworthy
None of the above
Please explain any behaviors checked above and common antecedent or triggers, resulting behavior, and consequences used at home, in therapy settings, and in the community.
Please list any other behaviors not mentioned above that we should be aware of so that we can provide the level of support needed. If none, enter N/A.
Do any of the above listed behaviors affect the applicant’s daily life? If so, how? If none, enter N/A.
List any obsessive compulsive behaviors. If none, enter N/A.
Does the applicant have a behavior support plan in place? If so, we request a copy of that plan during the application process.
Yes
No
Behavior Therapist First and Last Name
Behavior Therapist Phone Number
Behavior Therapist Email
Behavior Therapist Agency Name
Has the individual had any involvement with law enforcement? (ex: school, home, or community setting)If so, please explain. If not, enter no.
Emotional Responses (check all that apply)
Prefers to be by himself/herself
Does not like to be touched
Cries for no apparent reason
Bothered by excessive noise
Clings to other people
Gets upset if routine changes
Laughs for no apparent reason
None of the above
List things that scare or upset the applicant:
Please describe what helps to calm the applicant when he/she is sad, afraid, hurt, upset, etc.
Please check the following sensory inputs that your applicant might OVER REACT to.
Visual Stimultion
Lights
Heat
Thunderstorms
Fireworks
Sunlight
Touch
Animals
Sounds
Voices
None
How does the applicant react to pain?
Over reacts
Under reacts
Has a typical response to pain
Please note any other sensitivities and provide additional information.
Reinforcers
Edibles (food or drink)
Music
Tokens
Specific object
Preferred activity
N/A
Clarify any additional reinforcers not included above:
Describe manner of reinforcement
Fixed time interval (ie every 15 min)
Completion of task or activity
End of day
End of time period
N/A
Do you use a reward system as part of the behavior plan? If so, please describe it so we can use these during our programming. If none, enter N/A.
Activity Levels (check all that apply)
Has typical attention span and level of activity for his/her age
Has a short attention span
Less active / needs motivation to participate
Overactive
Easily distracted by sights, sounds, people, etc.
Please describe how you manage her/his activity level and motivate her/him to participate.
Please list any undesirable activities for your applicant. Please be specific.
List any INDOOR activities that the applicant enjoys. (ex: painting, acting, board games, etc.)
Check the types of OUTDOOR activities that the applicant enjoys.
Ball (bowling, volleyball, ball toss, basketball, kick ball, soccer, etc.)
Water (swimming, slip & slide, water balloons, sprinkler, water relays, etc.)
Sensory (bubbles, free play with lights, sounds, smells, textures, balance beams/balls)
Exercising (sit-ups/push-ups, hiking, jump rope, riding bikes, stretching, trampoline, walking)
Group (duck-duck-goose, kickball, musical chairs, parachute games, relay races, volleyball, etc.)
Individual in a group setting (yoga, petting animals, dancing, building, aerobics, etc.)
Individual (corn hole, swinging, frisbee, hopscotch, playground, putt-putt, etc.)
Swimming (check all that apply)
I am unsure of how s/he is in the pool
Swims well
Cannot swim
Must remain in shallow end of the pool)
Fears water / will not get in the pool willingly
Drinks pool water
Has bowel movements in the pool
Needs to wear a lifejacket in the pool at all times (you must provide)
Must wear earplugs in the pool (you must provide)
Enjoys waterslides
Does not enjoy waterslides
Are there any occupational or physical therapy goals that the applicant is working towards that would be helpful to share with us? If none, enter N/A.
What are the applicant's strengths?
What would you like for the applicant to get out of her/his experience at Dreams With Wings?
Is there anything else we should know about the applicant to make their experience a great one? The more we know about her/his likes/dislikes, skills, needs, behaviors, the better we can serve her/him.
How did you hear about Dreams With Wings?
Internet Search
Word of mouth
Referral from case manager
Referral from another organization (ex: FEAT, Council on Developmental Disabilities, etc.)
Social Media (Instagram, Facebook)
Other, please specify below.
If you checked other, please specify here.
Please upload a copy of your teen/young adult's behavior plan (if applicable)
Select a File
Submit