Club Aviva - Empowering Steps 2023-2024 Intake Form

Respondent (individual completing this form on behalf of the participant)

You will receive a confirmation by email.

First name *

Last name *

Email *

Mobile

Participant Information

Participant

First name *

Last name *

Preferred pronouns

Gender

Date of birth

Diagnosis(es) *

Other relevant past medical history

Medication(s)

Mobility *

Walking Non-walking

Speech *

Verbal Non-verbal

Vision limitations *

Yes No

Deaf/hard of hearing *

Yes No

Participant goals and/or areas of concern *

Areas of concern during the assessment *

Our shared space can be busy, loud, and will require sharing of equipment and adhering to safe pathways in the gym. To help us prepare for the assessment, please briefly describe the participant's characteristics with regard to:

communication, redirection (ex. use ASL, follows prompts, dislikes physical redirection, etc)
sensory seeking or sensitivities (ex. likes spinning or crashing, dislikes loud noise, etc)
anxiety, overwhelm, shutting down
any behaviours that are self-injurious or injurious to others
impulsivity and risk assessment

Other ongoing therapies

How did you hear about us?

Guardian Information

Guardian(s), support staff, and other relevant personnel

click "+ Add" to include multiple individuals

Relationship

First name *

Last name *

×

Preferred pronouns

Email *

Mobile

Gender

+ Add

Who will be dropping the participant off at the assessment?

Who will be dropping off the participant at ongoing sessions?

Assessment Information

Assessment fee *

The initial assessment is typically about 45-minutes in duration, with two Empowering Steps staff, and has a cost of $240. This amount can be paid prior to or on the day of the assessment. If you are planning to use third party funding (such as AFU, CKNW, or home school) and are in the process of receiving approval, we can refund the assessment fee to you once funding is established.

I understand and agree to the outlined assessment fee

Funding availability *

MCFD-AFU (Ministry of Child and Family Development - Autism Funding Unit) private other

Other

Therapies of interest *

Behaviour Intervention Movement Therapy Music Therapy SLP-Integrated Empowering Steps Physio-Integrated Empowering Steps Social Groups

Assessment availability

Assessments take approximately 45-60 minutes. Please enter as many days/times as you'd like by clicking "+ Add".

+ Add

0 hours