Transition to Life Participant Application

Project Criteria

  • Documented diagnosis of Autism Spectrum Disorder (Asperger Syndrome)
  • Ages 18-28
  • High level of motivation to meet program goals
  • Parent commitment and involvement
  • Mandatory attendance and weekly assignment completion
  • Ability to attend the course and work placement independently

FIRST NAME(*)
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LAST NAME(*)
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DATE OF BIRTH(*)
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dd/mm/yyyy

ADDRESS(*)
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City(*)
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PROVINCE(*)
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POSTAL CODE(*)
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PHONE #(*)
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CELL/OTHER #
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Email Address(*)
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Parent Email(*)
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GENDER
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FIRST LANGUAGE
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OTHER LANGUAGE
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EMERGENCY CONTACTS(S)

First

NAME(*)
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PHONE NUMBER
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Second

NAME
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PHONE NUMBER
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CURRENT RESIDENTIAL SITUATION(*)
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Other
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1. PRIMARY DIAGNOSIS AND OTHER AREA OF NEED
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A copy of an assessment of diagnosis will be required for intake

2. MEDICATION
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STABILIZED
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Please Specify
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3. OTHER SIGNIFICANT MEDICAL CONCERNS (i.e. Diabetes, Blood pressure, Allergies, etc.)
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Please Describe
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4. HISTORY OF BEHAVIORAL ISSUES (Verbal/Physical aggression, Threats/Bullying, Inappropriate Sexualized Behaviour, Violence Towards Self or Others?)
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Please Describe
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5. LEVEL OF COGNITIVE FUNCTION
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Explain
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6. INVOLVEMENT IN CONFLICT WITH THE LAW/CRIMINAL JUSTICE SYSTEM
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Please Indicate Involvement and date(s)
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7. SOURCE OF INCOME (check all that apply)
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Please Specify
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8. HIGHEST LEVEL OF EDUCATION
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What level of schooling in secondary school?
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9. Please provide your employment/volunteer history, starting with the most recent
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10. Describe your personal interests (hobbies, sports, etc.)
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11. List your strengths and challenges (what are you good at? What do you need help with?)
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12. Why would you like to attend the Transition to Life project?
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13. List 3 Goals that you would like to achieve during the project
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14. How did you hear about this project?
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15. Are you currently receiving any supports or services from any agencies? (Please Specify)
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16. How do you spend your time daily?
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17. What are you going to be doing next year?
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18. What would you like to be doing in 5 years?
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Parent Information

1. List 3 goals you would like your young adult to achieve
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2. Please explain any special considerations we should be aware of
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3. Are you available to support your young adult through this project and attend two, 2-hour workshops?
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Name of Applicant
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Name of Parent
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Please provide any additional notes not mentioned above.
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Prove You're Human
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All information on this form is confidential.
If you require assistance or have questions about this application, please contact us