Support Requirements for Early Intervention Step 1 of 2 50% IntroductionThis form asks questions about your child's preferences, interests, skills and personal care requirements so that we can understand how best to support them. Child's name(Required)Your goal for the program(Required)Please tell us your main goal for attending this MASS program.Communicates wants/needs Verbally With sign / compic With gesture When prompted Understands instructions(Required) In most situations Familiar instructions in unfamiliar environments Familiar instructions in familiar environments Rarely Level of support required for showering and grooming:(Required)IndependentlyWith supervisionWith verbal promptWith verbal & visual promptWith co-active helpUndress/dressWash handsShower him/herselfBrush teethBrush hairChoose clothingDressToilet independently - day timeToilet independently - night timeFeed him/herself with spoonFeed him/herself with forkUse knife and fork to cutLevel of support required for toileting and continence:ContinentRequires verbal/visual promptPartial/occasional incontinenceRequires assistanceTotal incontinence (nappy or pull up all the time)Bladder continenceBowel continenceMy child:(Required)Most timesSometimesRarelyNeverLikes to be aloneLikes company of other childrenLikes company of adultsSleeps through the nightBedtimeUsual bedtime(Required)Usual waketime(Required)Any bedtime routine?Food and drinkDoes your child have any physical difficulties which effect their eating (biting, chewing, swallowing) or drinking skills?(Required)What food and drink does your child like for breakfast?(Required)What food and drink do they like for lunch?(Required)What food and drink do they like for dinner?(Required)Does your child dislike any food or drink?(Required) BehavioursDoes your child display any repetitive behaviours, or have any obsessions?(Required)What happens if you interrupt them when they are engaged in a repetitive activity?(Required)Could any of these behaviours potentially cause harm to themselves or others?(Required)What strategies do you use at home to support your child?(Required)ActivitiesHow well can your child:Very wellNeeds some supportNeeds lots of supportNot well at allRide a bikeSwimCross the roadWalk with a groupBe out in the community (shops etc)Sit at the table during mealtimesAttend to and engage in an activity and/or game for 5 minutesUse pens and pencils to write or colourCatch and throw a ballPlay turn taking games with peersWhat activities does your child enjoy?(Required)What activities, if any, do they dislike?Are you currently implementing any programs with your child? Please describeWhat topics would you like to see covered in the parent education sessions?Other informationIs there anything else you would like Mansfield Autism to know?Acknowledgement I understand that the care provided includes maintaining a high level of personal hygiene. I acknowledge that, if indicated above, staff may provide co-active assistance when necessary to ensure this standard of care.
