First Name

Last Name

Date of Birth

Gender GenderMaleFemale

Address

City

State

Zip

Phone

Email Address

Diagnosis DiagnosisAutism Spectrum DisorderSocial Pragmatic Communication DisorderSpeech and Language DisorderOther

Guardian 1 First and Last Name (if applicable)

Relationship

Phone

Guardian 1 Email

Guardian 2 First and Last Name (if applicable)

Relationship

Phone

Guardian 2 Email

With whom do you reside? With whom do you reside? Parents / FamilyRoommateAloneOther

School School Will you/did you graduate from high school? Did you receive a GED?

Please list any colleges you attended (Include School Name, Degree/Major, Dates attended

College Degree College Degree

Independent Living: Please check independently, when asked to/prompted, need help, do not regularly do/engage in Independent Living: Please check independently, when asked to/prompted, need help, do not regularly do/engage in Chores: Independently Chores: When asked to/prompted Chores: Need help Chores: Do not regularly do/engage in Laundry: Independently Laundry: When asked to/prompted Laundry: Need help Laundry: Do not regularly do/engage in Basic food prep: Independently Basic food prep: When asked to/prompted Basic food prep: Need help Basic food prep: Do not regularly do/engage in Driving/Transportation: Independently Driving/Transportation: When asked to/prompted Driving/Transportation: Need help Driving/Transportation: Do not regularly do/engage in General Cleaning: Independently General Cleaning: When asked to/prompted General Cleaning: Need help General Cleaning: Do not regularly do/engage in

Social Communication : Please check independently, when asked to/prompted, need help, do not regularly do/engage in Social Communication : Please check independently, when asked to/prompted, need help, do not regularly do/engage in Greet others: Independently Greet others: When asked to/prompted Greet others: Need help Greet others: Do not regularly do/engage in Email: Independently Email: When asked to/prompted Email: Need help Email: Do not regularly do/engage in Use the phone/text: Independently Use the phone/text: When asked to/prompted Use the phone/text: Need help Use the phone/text: Do not regularly do/engage in Have regular conversations with people outside of immediate family: Independently Have regular conversations with people outside of immediate family: When asked to/prompted Have regular conversations with people outside of immediate family: Need help Have regular conversations with people outside of immediate family: Do not regularly do/engage in Remain on topic: Independently Remain on topic: When asked to/prompted Remain on topic: Need help Remain on topic Do not regularly do/engage in Start/initiate conversations: Independently Start/initiate conversations: When asked to/prompted Start/initiate conversations: Need help Start/initiate conversations: Do not regularly do/engage in

Employability: Please check independently, when asked to/prompted, need help, do not regularly do/engage in Employability: Please check independently, when asked to/prompted, need help, do not regularly do/engage in Identify interests: Independently Identify interests: When asked to/prompted Identify interests: Need help Identify interests: Do not regularly do/engage in Recognize areas of improvement: Independently Recognize areas of improvement: When asked to/prompted Recognize areas of improvement: Need help Recognize areas of improvement: Do not regularly do/engage in Ask for help: Independently Ask for help: When asked to/prompted Ask for help: Need help Ask for help: Do not regularly do/engage in Communicate with peers/employers: Independently Communicate with peers/employers: When asked to/prompted Communicate with peers/employers: Need help Communicate with peers/employers: Do not regularly do/engage in Follow directions: Independently Follow directions: When asked to/prompted Follow directions: Need help Follow directions: Do not regularly do/engage in

Have you previously been employed? Have you previously been employed? Yes

Where?

What were your job responsibilities?

What are your interests and hobbies?

What computer applications are you familiar with? What computer applications are you familiar with? Microsoft Word Powerpoint Email Social Media Other

Transportation Transportation Do you have a driver’s license ?

What transportation do you use to get to and from places? (short answer)

What do you do for fun? (short answer)

What motivates you? (short answer)