AIM Therapy Holiday Groups Expression of Interest

Child's Name

Does your child receive services with AIM Therapy?

Yes - current client

No - but received services in past

No - never received services

No - but wanting services

If answered "Yes - current client", who does your child see at AIM?

What age bracket is your child in?

What is your child's age?

Does your child have any diagnoses or delays? (For example, ADHD, speech delays, Autism, etc).

Does your child have any medical conditions? (For example, Diabetes, Epilepsy, Allergies, etc)

If your child does have a medical condition, how is it managed?

Describe any strengths your child has:

Language and communication capability of my child (tick all that apply)[Checkboxes]

Able to follow simple instructions

Difficulty following simple instructions

Able to express wants and needs

Difficulty expressing wants and needs

Able to express feelings

Difficulty expressing feelings

My child is a Gestalt Language Processer

Does your child use any tools to support communication? Do they use these tools independently or with support? (For example, an AAC device, sign language, etc.)

How much support does your child require to interact with same-aged children[Checkboxes]

1 - no support: child is independent when playing and socialising with peers.

2 - a little support: child needs some encouragement to start conversation and/or play with peers.

3 - some support: child requires more support to continue in play and social situations.

4 - significant support: child needs a lot of help to identify and engage in age-appropriate play expectations.

5 - complete support: caregiver supports all aspects of play and socialisation.

If your child requires support to interact with same aged peers, what does this look like? (For example, support to start conversation, appropriate vs inapropriate social interaction, etc.)

How much support does your child need to manage emotions and/or behaviours?[Checkboxes]

1 - no support required: complete independence in regulating own emotions.

2 - some support required: needing x1 visual/verbal prompt to use regulation tool or strategy.

3 – significant support required: significant prompting to transition away from trigger.

4 – complete support: needs 1:1 direct support from an adult.

Please describe any support needs or behaviours below (especially if you selected option 3 or 4).

For Example:
Types of behaviours can include absconding (running away), physical, verbal, self-injury, property damange.
Triggers can include noise, touch, words or activities, certain demands/instructions.
Regulation tools:Noise cancelling headphones, fidgets, movement breaks, deep pressure, anything specific to your child.

How independent is your child with toileting?
[Checkboxes]

Additional information: (E.g., completing toilet sits every hour (as recommended by specialist), unable to identify need to wee or poo, wears continence aides - diapers/nappies)

"Other" please specify:

Evaluation object score

AIM Therapy Holiday Groups Expression of Interest

Voice feedback