Social Connections Group Interest Form

Child/Participant's Name(Required)

First Last

Date of Birth(Required)

Age of Child/Participant(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone(Required)

Email(Required)

Parent/Guardian(s) Full Name(s)(Required)

County of residence (e.g. New Hanover, Brunswick, etc.)(Required)

Please share your ethnicity:(Required)

Asian

Black/African American

Caucasian/White

Hispanic or Latino

Native American or Other Indigenous

Native Hawaiian or Pacific Islander

Two or More Races

Other/Unknown

Prefer not to answer

Preferred Language in Your Home(Required)

English

Spanish

Other

Does the child have an autism diagnosis?(Required)

Yes

Uncertain

Please attach most recent and relevant diagnostic assessments. Drop files below or Select files to upload. Acceptable formats include: PDF, Word Doc, JPG, PNG, and GIF

Drop files here or

Accepted file types: png, pdf, jpg, gif, tif, doc, docx, Max. file size: 300 MB.

Funding (payment) source for group participation?*(Required)

Medicaid

Private Health Insurance

Out of pocket/Private payer

Medicaid County of Origin(Required)

In addition to Medicaid, does the child have ANY other health insurance policy/coverage?(Required)

Yes

Third Choice

Please upload front and back copies of the current Medicaid or private insurance card(s). Drop files below or Select files. Acceptable formats include: PDF, Word Doc, JPG, PNG, and GIF

Drop files here or

Accepted file types: png, pdf, tif, gif, jpg, doc, docx, Max. file size: 300 MB.

Is the individual currently enrolled in school?(Required)

Yes

If in school, in what setting does the individual receive most of their instruction? (separate /self-contained setting; resource setting; general education setting)

How does the individual communicate with others?(Required)

conversational

short phrases

very limited communication

Does the individual have any current behavioral challenges at school or home?(Required)

Yes

Please describe the behavioral challenges(Required)

Has the individual recently participated in formal social skills groups?(Required)

Yes

Was any aspect of the group particularly helpful? Please elaborate(Required)

Have you received any services from the Autism Society of North Carolina in the past 3 years?(Required)

Yes

Please list the program and type of Autism Society of North Carolina services

What are two specific goals that the individual would like to work towards in the social connection groups?

Please list 3-4 areas of interest/preferred activities of this individual(Required)

Please list 3-4 strengths of this individual(Required)

How were you referred to us?(Required)

MCO

Autism Resource Specialist

Social Media

Email notification

Physician/Therapist/Healthcare Provider

Provider Agency

Other

Today's date(Required)