Thank you for your interest in Aspirations!

Thank you for your interest in Aspirations!

The following is the enrollment packet for all Aspirations programs including forms for both the individual and caregivers to complete.

Please return completed forms to...

Erin Powers, MSW, LISW-S

By Mail: Attn: Erin Powers 285C McCampbell Hall 1581 Dodd Drive Columbus, OH 43210

By Fax: (614) 366.6373 -OR-

By Email: Erin.Powers@osumc.edu

If you have any questions or need more information, please contact Erin Powers at (614) 366-3276 or Erin.Powers@osumc.edu.

Enrollment Form-continued

Participant's Demographics:

Name:____________________ Date of birth:_______________________ Age:_____ Gender:___________________ Ethnicity:__________________________________ Address:_____________________________________________________________ Telephone #:_______________ Participant's Email Address:__________________ Diagnoses:___________________________________________________________ Date of diagnoses:_________________ Are You Your Own Guardian? Select Yes/No Diagnosed by:_________________________________________________________ Current medications:___________________________________________________

Participant's Interests:

List your top 3 interests:__________________________________________________ I am most proud of: _____________________________________________________ Someday I hope to: _____________________________________________________ This is what I hope to gain from Aspirations: __________________________________

Participant's Service History:

Do you receive county board of DD services? Select Yes/No Are you currently receiving SSI? SYeElSec/tNYOes/No Any current therapists/counselors: SYeElSec/t NYOes/NoWith Who: _____________________

Participant's Education History:

1.) Name and Location of School: _______________________________________ Year (s) Attended: _________________________ Average Grade(s) Achieved:_________________

2.) Name and Location of School: _______________________________________ Year (s) Attended: _________________________ Average Grade(s) Achieved:_________________

3.) Name and Location of School: _______________________________________ Year (s) Attended: _________________________ Average Grade(s) Achieved:_________________

4.) Name and Location of School: _______________________________________ Year (s) Attended: _________________________ Average Grade(s) Achieved:_________________ Page 2 of 7

Enrollment Form-continued

General history of activities: (including work, volunteering, and extracurricular experiences)

1.) Name and Location of Activity: _______________________________________ Brief Description of your Role: _______________________________________ Period of Involvement:______________________________________ Reason for Leaving:________________________________________

2.) Name and Location of Activity: ________________________________ Brief Description of your Role: ________________________________ Period of Involvement:______________________________________ Reason for Leaving:________________________________________

3.) Name and Location of Activity: _______________________________ Brief Description of your Role: _______________________________ Period of Involvement:______________________________________ Reason for Leaving:________________________________________

4.) Name and Location of Activity: _______________________________ Brief Description of your Role: _______________________________ Period of Involvement:______________________________________ Reason for Leaving:________________________________________

Participant's Family Information:

Name of parent(s): ____________________________________________________ Siblings (ages and names): _____________________________________________ Address of parent(s) if different than participants:____________________________ Parent(s) phone number(s):_____________________________________________ Parent(s) email address: _______________________________________________ Parent(s) Place of Employment:__________________________________________ Some activities our family is involved in: ___________________________________ I am/we are most proud of our son/daughter for: _____________________________ Someday, I/we hope our son/daughter ____________________________________ This is what I, the parent, would like to gain from being in Aspirations: ___________________________________________________________________

Page 3 of 7

Enrollment Form-continued

ASPIRATIONS PARENT QUESTIONNAIRE (To be completed by parent)

Name: __________________________________ Date: _______________

Directions: Check the answer that best describes how you feel. Please answer all the questions. If you do not know what a word or phrase means, please ask.

There are no right or wrong answers. Chose the response that comes closest to how you feel.

Strongly Agree Agree

Neither

Disagree

Strongly Disagree

1. My young adult is comfortable in a group setting.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

2. My young adult's problem-solving skills are strong.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

3. My young adult is self-confident.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

4. My young adult understands that their body language sends messages to others.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

5. My young adult has developed skills to resolve conflict in relationships.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

6. My young adult has clear goals for becoming more independent.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

7. My young adult understands that their personal appearance and hygiene are an important part of building relationships with others.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

8. My young adult is able to communicate with others in a group.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

9. Connecting with other people is easy for my young adult.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

Page 4 of 7

Strongly Agree

10. Other people see my young adult as a friendly Strongly

and polite person.

Agree

Agree Agree

Neither Disagree Strongly Disagree

Neither

Disagree

Strongly Disagree

11. My young adult understands the purpose of saying hello and goodbye to people.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

12. My young adult has practiced their communication skills by recording and watching themselves.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

13. My young adult recognizes when they have Strongly things in common with other group members. Agree

Agree

Neither

Disagree

Strongly Disagree

14. My young adult feels comfortable resolving difficult relationships through communication.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

15. My young adult understands the difference between relationships with friends and relationships with co-workers.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

16. My young adult's social media accounts send a positive message to others, including future employers.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

17. My young adult is aware of their personal strengths and how to use them in their lives.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

18. My young adult feels like they belong when they participate in a social event or a group activity.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

19. My young adult wants to practice skills that will help them be more independent.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

20. I am satisfied with the services I received from the Nisonger Center.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

Page 5 of 7

Enrollment Form-continued

ASPIRATIONS PARTICIPANT QUESTIONNAIRE (To be completed by participant)

Name: __________________________________ Date: _______________

Directions: Check the answer that best describes how you feel. Please answer all the questions. If you do not know what a word or phrase means, please ask.

There are no right or wrong answers. Chose the response that comes closest to how you feel.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

1. I am comfortable in a group setting.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

2. My problem-solving skills are strong.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

3. I am self-confident.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

4. I understand that my body language sends messages to others.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

5. I have developed skills to resolve conflict in relationships.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

6. I have clear goals for becoming more independent.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

7. I understand that my personal appearance and hygiene are an important part of building relationships with others.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

8. I am able to communicate with others in a group.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

9. Connecting with other people is easy for me.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

Page 6 of 7

10. Other people see me as a friendly and polite person.

Strongly Agree

Strongly Agree

Agree Agree

Neither Disagree Strongly Disagree

Neither

Disagree

Strongly Disagree

11. I understand the purpose of saying hello and goodbye to people.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

12. I have practiced my communication skills by recording and watching myself.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

13. I recognize when I have things in common with Strongly

another group member.

Agree

Agree

Neither

Disagree

Strongly Disagree

14. I feel comfortable resolving difficult relationships through communication.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

15. I understand the difference between relationships with friends and relationships with co-workers.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

16. My social media accounts send a positive message to others, including future employers.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

17. I am aware of my personal strengths and how Strongly

to use them in my life.

Agree

Agree

Neither

Disagree

Strongly Disagree

18. I feel like I belong when I participate in a social event or a group activity.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

19. I want to practice skills that will help me be more independent.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

20. I am satisfied with the services I received from the Nisonger Center.

Strongly Agree

Agree

Neither

Disagree

Strongly Disagree

Page 7 of 7

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