ASD Affinity Program - Hench Autism Studies

Applicant name: *

Mailing address: *

City: *

State: *

Zip code: *

County: *

Phone number: *

Email: *

Date of birth: *Example: 7/1/1999

Gender: *

Have you ever lived away from home before? *

If yes, please explain:

Have you ever stayed more than one (1) night away from your parents/guardians? *

If yes, please explain:

Have you been hospitalized for psychiatric reasons in the last five (5) years? *

If yes, please explain:

Have you been involved in any documented instances of aggression in the last five (5) years? *

If yes, please explain:

Have you ever had a job where you earned a paycheck? *

If yes, please explain:

Have you ever done any volunteer work? *

If yes, please explain:

Have you taken any college classes before? *

If yes, please explain:

What are some of your strengths? *

How do you learn best? What is the best way for someone to teach you something new? *

What are some things that are difficult for you? *

Have you ever had a substance abuse problem (e.g., addiction or abuse of drugs or alcohol)? *

If yes, please explain:

Have you completed and submitted your application for Defiance College? *

Please use the space below to write any additional information that you think is important for us to know about you:

APPLICANT PERFORMANCE RATINGS

This is information about the applicant. This section should be completed by the applicant without input from other individuals.

Please complete this questionnaire by selecting the performance level (PL) that you think best describes your current skill level and ability for each of the items. We will use this information to learn more about you as an individual.

PL-0 No Participation: You refuse to participate in the learning opportunity. This means that you choose not to try to do an activity.

PL-1 Early Instruction: You need prompts for most, or every, step in the task. This means that you need direct 1:1 assistance to complete the task. This means that you need someone to help you with every step of the activity.

PL-2 Guided Practice: You need specific prompts (e.g., verbal, written, gestural) to complete the task, but you do not need prompting for each step in the sequence. This means that you need help with the activity, but that you can do some parts of it on your own.

PL-3 Guided Independence: You need general prompts to complete the task (e.g., a reminder that it is an expectation to complete the task) or you complete the task within the structure of a program (e.g., because that is part of your routine at school). This means that when someone reminds you to do the activity or if it is a part of your routine you do it without any other help.

PL-4 Independent: You do not require additional instructions, prompting, or other assistance to complete the task. You independently seek resources as needed. This means that you do this activity without anyone reminding you or putting it in your schedule.

N/A: You have never had the opportunity to try this. This means that you have never been able to try the activity.

Making a simple meal (examples: canned soup, sandwich, frozen pizza, salad): *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Doing laundry. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Waking up on time and getting ready for the day. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

General upkeep of living space. General upkeep includes washing dishes, wiping down counters, vacuuming, mopping, cleaning the bathroom, and taking out the garbage. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Organizing your living space so you can easily find things. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Managing your time to balance non-preferred and preferred tasks. For example, ensuring that you turn your xbox off by 8:00 pm so you can study for an upcoming exam. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Maintaining good personal hygiene. Examples of good personal hygiene practices are brushing your teeth daily, showering regularly, washing your hands after using the bathroom, and wearing clean clothes. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Scheduling medical and mental appointments. Examples of medical appointments are check-ups with the doctor, dentist appointments, or an appointment with your psychologist/psychiatrist. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Attending medical and mental health appointments. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Treating minor injuries at home. Examples of treating minor injuries include scrapes, first degree burns, splinters, and insect bites. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Identifying and taking appropriate over the counter medications for minor ailments. Examples of minor ailments include headache, congestion, and heartburn. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Taking regular medications. Regular medications are medications that you take every day. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking my peers for clarification when I am unsure what they mean. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking authority figures for clarification or help when I don’t understand something. Examples of authority figures are professors and supervisors. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Asking people in the community, who I don’t know, for assistance. Examples of people in the community are servers at restaurants and cashiers at the store. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Using Technology to connect with classmates and friends. Examples would be texting, twitter, and instagram. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Telling a peer that something is bothering me without becoming verbally or physically aggressive. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Advocating for myself if a need is not being met or if I need assistance. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Finding resources in the community by using the internet. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Understanding who to share personal information with and who not to. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

Accepting feedback or correction from others in an appropriate way. *

PL-0

PL-1

PL-2

PL-3

PL-4

N/A

What are the academic and career goals that you hope to accomplish at Defiance College? *

What are the life skills goals that you hope to accomplish at Defiance College? *

What are the interpersonal and recreational goals that you hope to accomplish at Defiance College? *

Please be sure to submit all supporting materials with your application.

Current psychological evaluation or Evaluation Team Report (ETR) conducted within the last 3 years and including:
- Results from intelligence testing (e.g., Stanford Binet IV, WAIS-IV)
- Results from achievement testing (e.g., Wechsler Individual Achievement Test, Woodcock Johnson Tests of Achievement)
  Note: Results should include subtest scores and a detailed narrative.
Documentation of ASD diagnosis/qualification of services
Most recent individualized educational plan (IEP), if applicable
Two letters of reference from a high school teacher, counselor, therapist, and/or principal. Letters of reference should speak to your preparation for college level academics and college life.
Parent or Support Person Performance Ratings

Supporting documentation can be submitted by email to autism@defiance.edu or post mail to Clarissa Barnes, ASD Affinity Program, 701 N. Clinton Street, Defiance, OH, 43512.

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