F2B1

Date of Birth (Month/Day/Year)*

COVID-19 Policy Advisory and Agreement: Current operational policy at CARD requires all individuals in the facility be masked except for individuals exempt by age or medical status. Vaccination is strongly reccommended. By checking the boxes below, I agree to comply with both policies and to provide a copy of my vaccination certificate, if requested.
Yes- I will wear a mask

Yes- My child will wear a mask

No- I and/or my child are not mask compliant

How did you hear about CARD?

Reason for application to CARD program

Please check all areas of interest:*
Mounted physiotherapy Psycho-education class Physical rehabilitation class Horsemanship (adapted sports)

Equipment needs

Equipment (please check all that apply)*
Orthotics/AFOs/Braces Walker Stander Wheelchair Adapted seating Communication aids

Other splints Other (Please elaborate below)

Equipment (if other than options above)

Areas of concern

Areas of concern (please check all that apply)
Range of motion/flexibility Strength Mobility Balance Motor planning Spatial/body awareness

Coordination Sensory behaviour Physical fitness Social skills Communication Other (please elaborate below)

Areas of concern (if other than options above)

Other relevant information/comments:

Diagnosis:

Diagnosis*

When did you receive your diagnosis (es)?*

Was the push toward diagnosis instigated by family or medical professionals?*

What signs/symptoms led to a diagnostic investigation?*

Current therapies, goals and therapist names

OT:

OT Terapist's Name(s):

PT:

PT Therapist's Name(s):

SLP:

SLP Therapist's Name(s):

Other:

Communication

What is the preferred method of communication: verbal? Sign language? PECs? Augmented communication?*

Are any languages other than English spoken/understood?*

For written/augmented and/or verbal communication, please indicate if full sentences are used, or if partial sentences of 2-3 words are used.*

School:

Does the applicant attend a regular school, a school that is integrated or one devoted only to special needs students?

What grade level is the applicant currently working at? (this may not be the same as their chronological grade level)

How many students are in the class?

How many support staff/teachers?

Behaviour/Sensory Challenges

Are there particular phrases that should be used or avoided?

Environmental setup? i.e. visual schedules/timers, use of noise cancelling headphones, etc.

Sensations the applicant avoids?

Sensations the applicant seeks?

Reward systems currently in use?

Deterrent systems currently in use?

Strategies for Success:

Please share if the applicant responds to a particular approach or personality type, i.e. quiet demeanors, highly animated interaction, etc.