Potential Autism Program Interest Form  
We are graduate occupational therapy students at The University of Scranton working alongside the Autism Collaborative Centers for Excellence to design a program that your children can potentially participate in the Spring 2022. If you are the parent or caregiver of a child/children ages 3-10, please fill out this Google Form. The information we receive from this short survey will help us tailor a program to best fit the needs of your children. Feel free to provide as much or as little information as possible, anything helps!
*If you are interested, please have your responses back to us by Monday, September 20th!
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How old is your child?
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List any diagnoses your child has, if applicable.
Have you previously participated in a program with the Autism Collaborative Centers for Excellence?
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If yes, please specify if it was in person or virtual.
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If you have attended a group, do you have any feedback, either positive or negative?
What are some areas that your child excels in?
What are some areas that your child can benefit from having more practice on?
What life skills would your child like to work on?
What program do you believe your child would be most interested in, please check all that apply:
The goal of this program is to be held in person. However, given the ever-changing circumstances of the pandemic, would you be interested in any virtual offering of a program for your child?
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List the ideas you have for a virtual offering:
Would you be willing to do a follow up interview to get more detailed information on what your child would benefit from?
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If so, please provide your email or phone number.
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