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Autism Program Application

To apply for ILRC’s Greater Expectations autism program, please download the application form and then follow the instructions. You can also fill out the online form below.

Application Forms

Application information must be completed by potential participants as well as parent/caregiver (when applicable).
Include all pertinent medical/diagnostic/assessment information.
Submit completed information to borth-voegeli@ilrcks.org, drop it off in person, or mail it to Independent Living Resource Center at 3033 West 2nd St N. Wichita, KS 67203.
Upon review, you will be contacted with further information

Download Application Form

Apply For The Autism Program Online

"*" indicates required fields

Step 1 of 5

20%

Form Completed By*

Relationship to individual:*

Date Completed

Individiual Information

Name

Gender*

Age*

Birthday*

MM slash DD slash YYYY

Address

Street Address City State / Province / Region Zip

Referred by:*

Is the individual registered to vote?

Yes

Does the individual have a legal guardian?

Yes

Parent/Guardian Information

Name(s)

Address

Street Address City State / Province / Region Zip

Phone Number(s)

Email(s)

Primary Language

Reason(s) seeking these services?*

Emergency Contact

Other Than Parents/Guardians

Name

Address

Street Address City State / Province / Region Zip

Phone Number

Current Diagnoses and Concerns

Primary Diagnosis:*

Age at time of diagnosis

Professional who made the diagnosis

Comorbid Diagnosis*

Age at time of diagnosis

Professional who made the diagnosis

Comorbid Diagnosis*

Age at time of diagnosis

Professional who made the diagnosis

Comorbid Diagnosis*

Age at time of diagnosis

Professional who made the diagnosis

Areas of current concern or struggle (check all that apply)*

aggression

overactivity

depression

anxiety

appetite/food selections

motor skills

self-injury

inattentive

muscle tone

Sensory Integration

explosive temper

sleep problems

self-help skills

self-stimming

medications

peer relationships

motivation

other

If Other, please list*

Current Living Environment

With whom does the individual currently reside? (please mark all that apply)*

lives independently

mother

father

spouse/life-partner

stepmother

stepfather

group home

siblings

step siblings

peers/roommates

other

If Other, please list*

Medical History

Has the individual ever had:*

Serious Head Injury

Loss of consciousness(LOC)

Frequent Headaches/Migraines

Sleep Problems

Neurological Problems

Seizures (type)

Asthma

Diabetes

Autism/PDD

ADHD

Learning Disability

Emotional Trauma

Oppositional defiant disorder

Anxiety Disorder

Obsessive-compulsive disorder

Depression

Bipolar Disorder

Schizophrenia

Tourette Syndrome

Eating Disorder

Physical/Sexual Abuse

Dementia/Alzheimer's

Other

Please describe the head injury, age of individual, and family history

Please describe the loss of consciousness, age of individual, and family history

Please describe the seizures, age of individual, and family history

Please describe the asthma, age of individual, and family history

Please describe the sleep problems, age of individual, and family history

Please describe the neurological problems, age of individual, and family history

Please describe the learning disability, age of individual, and family history

Please describe the diabetes, age of individual, and family history

Please describe the autism/pdd, age of individual, and family history

Please describe the ADHD, age of individual, and family history

Please describe the emotional trauma, age of individual, and family history

Please describe the oppositional-defiant disorder, age of individual, and family history

Please describe the anxiety disorder, age of individual, and family history

Please describe the obsessive-compulsive disorder, age of individual, and family history

Please describe the depression, age of individual, and family history

Please describe the bipolar disorder, age of individual, and family history

Please describe the schizophrenia, age of individual, and family history

Please describe the Tourette syndrome , age of individual, and family history

Please describe the Eating Disorder, age of individual, and family history

Please describe the physical/sexual abuse, age of individual, and family history

Please describe the dementia/alzheimer's, age of individual, and family history

Hospitalizations, surgeries, or procedures (medical and behavioral)*

Add the reason for hospitalization/surgery/procedure, the age, and length of stay

Please List All Allergies

List the source of the allergy (medication, food, etc...) and the nature of the reaction (hives, trouble breathing, etc...)

Doctors seen now or in the past*

General Physician

Neurologist

Genetics

Psychiatry

Gastroenterology

Medical History Cont.

Please list the name, start date, reason, and prescriber for each current medication the individual uses.*

Please list the name, start date, reason, and prescriber for each discontinued medication the individual uses.*

Current Healthcare Providers

Primary Care Provider

Neurologist

Mental Health Provider

Medication Manager

Other

Please list the name and phone number of the primary care provider

Please list the name and phone number of the neurologist

Please list the name and phone number of the mental health provider

Please list the name and phone number of the medication manager

Please list the name(s) and phone number(s) of any other healthcare providers

Please list the name(s), phone number(s), and specialty of any former healthcare providers

Educational History

Individual’s Highest Level of Education*

11th grade or less

GED

High School Graduate

Associates Degree

Bachelor’s Degree

Graduate/Professional

Vocational Certificate

Please list all of the schools, including college or community college, the individual has attended:*

Vocational History

Is the individual currently employed?*

Job Title:*

Employed since:*

MM slash DD slash YYYY

#of hours per week:*

Previous Employer(s). Please list: Job Tasks, Dates, and # of hours worked a week*

Current/Former Services

Services the individual uses currently or has used in the past

Counseling

Speech Therapy

Occupational Therapy

Physical Therapy

Medical Treatments

Vocational Rehabilitation

WIOA

Targeted Case Management

Day Services

In-Home Care

SSI/SSD

Please list the service, provider name, frequency, current or date ended of the services selected above*

Additional Information:

Once submitted, you will receive a Thank You message to confirm your application was submitted correctly. If you do not receive this message, please double-check and make sure you have completed all fields.

Comments

This field is for validation purposes and should be left unchanged.

Autism Program Application

Application Forms

Apply For The Autism Program Online

Individiual Information

Parent/Guardian Information

Emergency Contact

Current Diagnoses and Concerns

Current Living Environment

Medical History

Medical History Cont.

Educational History

Vocational History

Current/Former Services

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