Healthy Relationships, Sexuality and Autism Program Application

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Healthy Relationships, Sexuality and Autism Program Application - Spring 2021 Cohort

This application form is used to provide program staff with useful information about the participant. We recognize not all questions will be relevant. All information acquired will be held in strict confidentiality to be used only by Autism Nova Scotia employees.

Given the nature of this program, sensitive topics will be discussed. It is important that the person applying to participate in this program take an active role in completing this application so we have an understanding of their level of comfort and interest in the program. With that, we request that Part Two of this application be completed by or directly with the participant. If you wish to have a copy of these questions before submitting the application, please email Holly (email below).

The Spring Cohort of HRSA will begin in April 2021 and will be delivered online. Program participants will require internet access to participate, as well as access to a device to use the video calling program Zoom to join sessions. Participants can join from anywhere in Nova Scotia.

If you have any questions please contact Holly MacLellan, HRSA Program Coordinator

Email: hmaclellan@autismns.ca
Phone: 902-410-6721 (cell)

Please put the MAIN EMAIL that you wish to use for all communications relating to this program *

Please put the MAIN PHONE NUMBER that you wish to use for all communications relating to this program *

Who is completing this form? *

I am filling out this form on my own for myself.

I am filling out this form for myself, with help from someone else.

I am filling out this form for someone else.

Participant's Name *

Phone Number *

Email Address *

Age *

Birthdate *

YYYY

Home Address *

Name of Emergency Contact (HRSA staff do not communicate with parents/caregivers without participant consent) *

Phone Number of Emergency Contact (HRSA staff do not communicate with parents/caregivers without participant consent) *

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