Forms and Datasheets
Therapist Timesheet
Name: ________________________________ Round time to nearest 5 min.
Video Tape Permission
In order to video tape my son, CK, I must have permission from all parents of children that may come in contact with CK during video taping. Video taping occurs to teach parents of CK and train Aides how to better teach CK to interact with his peers.
Please sign the form below. If you have any questions about video taping, CK, or autism, please call, email, or visit our website:
John Doe
Home 555-1212
Work 555-2121
CK's team appreciates your interest and cooperation in helping,
John Doe
Consent for Photographs, Movies, or Television
I, the undersigned, hereby authorize photographs and/or movies of ____________________________________(name of participant) by the representatives of the above-named program or other designated persons to be viewed by the above-named program staff in contributing to the educational development of this staff in the advancement of teaching techniques and program activities.
_________________(date)
_______________________________(signature of participant - if applicable)
_______________________________(signature of parent/guardian)
Sample Help Wanted
WANTED
Someone to make a difference in the life of a child with autism.
Tutors needed for sessions between 9am and 4pm weekdays in Corvallis. (Minimum of 6 hours/week) Weekends/other hours negotiable. Only requirements are patience, big heart, and willingness to learn. Continual training provided. 6 month commitment needed. Pay starting at $8 per hour (depending on experience). Call John Doe. Home 555-1212, work 555-2121. Come join our team!
Least Restrictive Environment Worksheet
Part 1- Primary Placement
( ) Can the child's needs be met in the general education class without any additional support?
( ) Can the child's needs be met in the general education class with additional supports and modifications?
( ) Can the child's needs be met in the next, more segregated class with services in place now?
( ) Can the child's needs be met in the next, more segregated class with additional supports or modifications?
Considering the continuum from least restrictive to most restrictive, the IEP team should ask and answer the last two questions above ONLY UNTIL A YES ANSWER IS OBTAINED.
Primary Placement:
Part 2- Additional Opportunities for Inclusion
Even after the primary placement is determined, consider additional opportunities for part-time integration. (List all that apply).
( ) During the school day (at same school)
( ) At a different school
( ) After school
( ) Community activities
( ) Employment or job training opportunities
( ) Other