ࡱ> y pebjbj e{{.86Tnd&+(+(+(+F- ::At c c c c c c c$fh/cD$-$-"DD/c(+(+(dbZbZbZDF(+(+ cbZD cbZbZ\E](+Dv]b>d0nd],iNEr iE]iE]DDbZDDDDD/c/cO DDDndDDDDiDDDDDDDDD :  Application for Service Service Required: Date Form Requested:  FORMTEXT       Day  FORMCHECKBOX  Residential  FORMCHECKBOX  Outreach (Adult)  FORMCHECKBOX  Outreach (Children)  FORMCHECKBOX  Supported Living  FORMCHECKBOX  Other  FORMCHECKBOX  please specify:  FORMTEXT        Section A - Applicant Details: Name:  FORMTEXT       Date of Birth:  FORMTEXT      Address:  FORMTEXT      Gender:  FORMTEXT       Religion:  FORMTEXT       Telephone No.:  FORMTEXT       Mobile No.:  FORMTEXT       Email:  FORMTEXT        Section B - Parent / Guardian / Carer Details: Father / Guardian / Carer Name:  FORMTEXT       Mother s Name:  FORMTEXT      Address:  FORMTEXT       Address: (if different from opposite)  FORMTEXT       Telephone No.:  FORMTEXT       Mobile No.:  FORMTEXT       Email:  FORMTEXT       Telephone No.:  FORMTEXT       Mobile No.:  FORMTEXT       Email:  FORMTEXT        Siblings: (Please list)Gender:Date of Birth: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Section C - Condition Details: Diagnosis:  FORMTEXT       Diagnosed by:  FORMTEXT       Nature of Disability:  FORMTEXT       Age at onset of condition:  FORMTEXT       Any other known disability (please specify)?  FORMTEXT       Does applicant suffer from epilepsy? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is there any evidence of hearing or visual impairment? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Section D - Personal Health: Is the applicant on any medication? (give details): Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       Has the applicant had any serious illness? (please describe): Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        Details of any known allergies:  FORMTEXT        Section E - Placements: Present Placement or Service (School, Centre, Employment):  FORMTEXT       Please give reasons for wanting another facility:  FORMTEXT        Previous Placements: Placements / SchoolsDate of EntryDate of Leaving FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Section F - Communication: Applicants first language?:  FORMTEXT       Does the applicant use spoken language? (please describe): Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT       Use of gesture / mime (please describe):  FORMTEXT       Articulation, e.g. echolalic, stilted speech, etc (please describe)  FORMTEXT       How much can the applicant understand what is said to them? (please describe):  FORMTEXT        Section G - Relationships (please describe): With Family:  FORMTEXT       With Other young people:  FORMTEXT       With Adults:  FORMTEXT       Has the applicant lived away from home before (give details): Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMTEXT        Section H - Motor Co-ordination (please describe):  FORMTEXT        Section I - Self Care: Can applicant (please x all that apply): Independently xVerbal Prompt xPhysical Assistance xUse knife and fork  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Bathe him / herself  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Clean teeth  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Comb hair  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Wash hair  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Manicure / pedicure  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Get up without being called  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Change clothes appropriately  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Shave (wet / electric)  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Dress him / herself FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Know when to change clothes FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Personal hygiene  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Clean shoes  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Prepare drinks / snacks  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Section J - Social Adequacy: Any difficulties with: Using toilet adequately: Day - Yes  FORMCHECKBOX  No  FORMCHECKBOX  Night - Yes  FORMCHECKBOX  No  FORMCHECKBOX  Eating (please describe):  FORMTEXT       Sleeping (please describe):  FORMTEXT       Obsessions and ritualism (please describe):  FORMTEXT       Is the applicant over active? Yes  FORMCHECKBOX  No  FORMCHECKBOX   Section K - Behaviour Problems (please specify): Yes xNo xAdditional CommentsTemper control FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Aggression FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Self Injury (biting, hitting, head banging) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Destructiveness (breaking, chewing) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Screaming / roaring FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Running away FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Tearing FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Any other information:  FORMTEXT        Section L - Educational Attainments: Can applicant: Yes xNo xAdditional CommentsRead (please specify) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      If not, can they recognised signs such as  Keep Out ,  Do Not Touch ,  Ladies / Gentlemen ?  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Write (name / letters) FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Tell time FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Recognise money FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Do they have any idea of purchasing power of money?  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leisure time? Yes xNo xAdditional CommentsOutdoors  Can they use public transport? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Are they reliable in traffic? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play ball games? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they swim? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they ride a bicycle? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Any other information:  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Indoors Can they use a computer?  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they watch television? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play musical instruments? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play card games? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play skittles? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play table tennis? FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Can they play badminton?  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Any other information:  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       Section N - Occupational Skills  (please specify): Likes (please specify): FORMTEXT       Dislikes (please specify):  FORMTEXT      How long will they concentrate on any given task?  FORMTEXT       Are they able to accept direction and work without constant supervision? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Areas of support shown by applicant:  FORMTEXT        Section O - Any other relevant information: Please attach reports from Schools / Hospitals / Adult Training Centres , etc. Have you applied to any other facility for placement? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If YES, please state:  FORMTEXT        How did you learn of the services NORSACA provides?  FORMTEXT       Who did you contact to request this  Application for Placement Services Form?  FORMTEXT        Section P - Funding: Does the Local Authority support this application? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is this application placement being funded by Adult Health & Social Care / Children s Services?Yes  FORMCHECKBOX  No  FORMCHECKBOX Is this application placement being funded by Aiming High Funding?Yes  FORMCHECKBOX  No  FORMCHECKBOX Is this application placement being funded by Carers Grant funding?Yes  FORMCHECKBOX  No  FORMCHECKBOX Please specify any other funding that is being used:  FORMTEXT        Section Q - Declaration: We acknowledge and understand that: this form should be returned to the address below within 4 weeks of the date it was requested, to enable Assessment visits to be arranged Challenging Behaviour  Individuals with autism spectrum condition will experience anxiety and / or distress where there are changes to routine, environment, structure or support plans. Visitors may also bring about anxiety. On these occasions an individual can demonstrate extreme behaviour, which is often referred to as challenging behaviour. Challenging behaviour can include outbursts of anger, hitting or kicking other people, throwing things or hurting themselves. Living with challenging behaviour can be a stressful and exhausting time for the individual displaying the behaviour; other people sharing the environment and the staff team. Challenging behaviour is not just a  stage that an individual with autism spectrum condition will grow out of. It often appears in individuals who have difficulty communicating their needs and wishes in other ways. At these times, through sensory overload or by frustration of communication, an individual with autism spectrum condition may lose control of their emotions and strike out spontaneously and indiscriminately. Although, regrettable, these are not actions of intent and should be considered within the context of the service provided. NORSACA will always work towards supporting all parties when incident occur. Signed by person completing this application (typing name will be accepted as a signature):  FORMTEXT      Signed by Social Worker or other Professional supporting this application (typing name will be accepted as a signature):  FORMTEXT       Print Name:  FORMTEXT       Print Name:  FORMTEXT      Relationship to applicant:  FORMTEXT       Position:  FORMTEXT      Contact Address:  FORMTEXT       Tel. No.:  FORMTEXT       Email:  FORMTEXT       Contact Address:  FORMTEXT       Tel. No.:  FORMTEXT       Email:  FORMTEXT       Date:  FORMTEXT       Date:Sponsoring Authority:  FORMTEXT        Please use attach additional supporting information, if appropriate, indicating which section is applies to Please return completed form to: - NORSACA, Eastwood House, 10 Mill Street, Clowne, Derbyshire, S43 4JN Email:  HYPERLINK "mailto:bevb@norsaca.org.uk" bevb@norsaca.org.uk Revised: 01.11.2011      PAGE 5  <B<D<<<<<<<<<<<<====H=J=f=h=j=l=n=======ŶŶŶҶŁpŁ_Ł!jh66OJQJU^J!jh66OJQJU^Jjh66OJQJU^J h66h66h}7CJOJQJ^Jh66OJQJ^JhGdOJQJ^Jhh}7CJOJQJ^Jhh}7OJQJ^Jhh}7>*OJQJ^J h66h9CJOJQJ^JaJhh}75OJQJ^J<<<<< $$Ifa$gd P< $$Ifa$gd P<<<<=2) $Ifgd P< $Ifgd}7kdƂ$$Ifl\f!l($K (0(64 lap(ytd===== =H=H= P$Ifgd66kd$$Ifl\f!l($K0(64 la $Ifgd P< $Ifgd66 $$Ifa$gd66H=l=====>>>f>QF P$Ifgd66kd$$Ifl\f!l($K0(64 la $Ifgd P< $$Ifa$gd66=======>>>>>8>:><>>>@>T>V>X>b>d>>>>>>>>>>>>>>൤൓ൂq`!j#h66OJQJU^J!jh66OJQJU^J!jh66OJQJU^J!j h66OJQJU^J!jh66OJQJU^Jh66OJQJ^Jhh}7OJQJ^J&jh66OJQJU^JmHnHujh66OJQJU^J!jh66OJQJU^J"f>h>>>> 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