Student Information

Child's Name

Birthdate      Age

Address

City       State

Zip    Phone

Weight    Height

School    Grade Completed

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Main Contact Information

Who should we contact about this application?

Name

Relationship to child

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Phone

General Information

Describe how satisfied you are with your child's current school setting.

Current Diagnosis: A copy of the most recent testing is required with the application.

This information will not be used to exclude participation. It is for information only.

Executive Functioning skills Difficulty handling transitions, shifting from one mindset or task to another, adapting to new circumstances or rules Poor sense of time/difficulty doing things in a logical or prescribed order Disorganized/difficulty staying on topic, sorting through thoughts, or keeping track of things Difficulty considering the likely outcomes or consequences of actions (impulsive) Difficulty considering a range of solutions to a problem

Self-regulation and Self-awareness Will go to an adult to be soothed when upset or angry. Will follow instructions when adults tell him/her what actions and places are safe and not safe. Will follow the rules for physical contact so as not to bother or hurt others. Will use tools and strategies to calm when upset or angry. Will pay attention to adults when they request attention. Will stop negative behaviors to avoid suffering consequences.

Language processing skills Often has difficulty expressing thoughts, needs, or concerns in words Often appears not to have understood what was said Long delays before responding to questions Difficulty knowing or saying how he/she feels

Emotion regulation skills Difficulty staying calm enough to think rationally (when frustrated) Cranky, grouchy, grumpy, irritable (outside the context of frustration) Sad, fatigued, tired, low energy Anxious, nervous, worried, fearful Inaccurate interpretations/cognitive distortions or biases (e.g., "It's not fair," "I'm stupid," "Things will never work out for me")

Cognitive flexibility skills Concrete, black-and-white, thinker; often takes things literally Insistence on sticking with rules, routine, original plan Does poorly in circumstances of unpredictability, ambiguity, uncertainty Difficulty shifting from original idea or solution; possibly perseverative or obsessive Difficulty appreciating another person's perspective or point-of-view Doesn't take into account situational factors that would suggest the need to adjust a plan of action

Social skills Difficulty attending to or misreading of social cues/poor perception of social nuances/difficulty recognizing nonverbal social cues Inaccurate interpretations/cognitive distortions or biases (e.g., "Everyone's out to get me," "Nobody likes me," "You always blame me") Lacks basic social skills (how to start a conversation, how to enter a group, how to connect with people) Seeks the attention of others in inappropriate ways; seems to lack the skills to seek attention in an adaptive fashion Seems unaware of how behavior is affecting other people; is surprised by others' responses to his/her behavior Lacks empathy; appears not to care about how behavior is affecting others or their reactions Poor sense of how s/he is coming across or being perceived by others Inaccurate self-perception

Academic Competency Has difficulty remaining focused for a 45-minute class period. Has difficulty reading to find answers. Unable to use tools to accomplish writing tasks. Has difficulty setting and maintaining a productive pace of work.

What are some "triggers" that result in dysregulation? 1. 2. 3.

What is your goal for your child during the summer program experience?

NOTE: New camp students will be assessed a $30.00 screening fee at the time of his/her interview. The Program Director will notify you of acceptance and placement will be secured with $250 deposit.