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Posted on January 8, 2019January 8, 2019 by admin

SUNY UNIVERSITY AT BUFFALO

Department of Communicative Disorders

Categoriesacademic

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3800 Delaware Avenue Suite 103 Kenmore, NY 14217

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Please indicate the presence of a developmental disability, if any (check all that apply):

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What level of support is needed for the applicant to be successful?

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Does the applicant require the assistance of an aide for personal care or management needs?

Yes, 1:1 aide

Yes, shared

No

I understand that C-HOPE cannot provide assistance for personal care needs such as toileting and eating.

Did/does the applicant have a Behavior Intervention Plan (BIP)?

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No

How does the applicant communicate? Check all that apply.

Verbal - carries on full conversations. Are there articulation challenges?

Verbal - carries on limited conversations. Articulation challenges?

Echolalia (repeats words and/or phrases)

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Does the applicant have any allergies? (e.g., medication, food, bee stings, latex, etc.)

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If yes, please provide detail

Is an EpiPen required for any allergy?

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If yes, please provide detail

Please list any dietary restrictions the applicant may have.

In the event of a serious emergency (e.g., fire), what is the most critical piece of information about the applicant do you want us to share with first responders?

Is the applicant fearful of or adverse to any of the following? Check all that apply and provide detail.

Loud noises

Animals/Insects

Textures

Siren/Fire Alarm

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None of the above

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Do any of the following frustrate the applicant? Check all that apply and provide detail, as necessary.

Noise

Raised voices

Touch/Touching

Bright lights

Cold temperature

Hot temperature

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Are there any key words, phrases, or other stimuli that should or should not be used with or around the applicant?

Please list requested accommodations. C-HOPE willl consider requests as program limitations allow.

Please list interests and hobbies of the applicant.

In order to maximize the applicant's experience in this program, please provide additional information that would be valuable for C-HOPE staff to know.

PARENT / GUARDIAN INFORMATION

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Please be sure to include the following with your application:

Program application

$25 non-refundable deposit (checks payable to C-HOPE Inc.)

Consent/Release forms

Medication self-carry/administer documentation, if applicable

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