Name: Integrated Autism Consulting
Address: 134 Collier St., Barrie, ON, L4M 1H4, Canada
Telephone: (705) 252-3114

Project Criteria

Participant Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Cell/Other
Email*
Parent Email*
Gender
First Language
Other Language

Emergency Contacts
Name*
First Last
First Emergency Contact
Phone
First Emergency Contact
Name*
First Last
Second Emergency Contact
Phone
Second Emergency Contact
Current Residential Situation
- Family Home
- Own Residence
- Group Home
- Other
Primary Diagnosis and Other area of Need
Medication
- Yes
- No
Stabilized
- Yes
- No
Please specify:
Other significant medical concerns (i.e. Diabetes, blood pressure, allergies, etc.)
List your strengths and challenges (What are you good at? What do you need help with?)
Why would you like to attend the Transition to Life course?
List 3 goals that you would like to achieve during the course..
How did you hear about this course?
Are you currently receiving any supports or services from any agencies? (Please specify)
How do you spend your time daily?
What are you going to be doing next year?
What would you like to be doing in 5 years?

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All information on this form is confidential.
If you require assistance or have questions about this application, please contact us