Fillable Customer Profile (Page 2 of 3) in pdf

Customer Profile Page 2

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Complete Customer Profile with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Primary Diagnosis:

Choose One

Secondary Diagnosis:

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Mild

Moderate

Severity of Disability

Interaction skills

Please rate on a 1 to 5 scale with 5 being strongly agree and 1 being strongly disagree.

Comprehends and learns through verbal directions

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Speaks and is clearly understood

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Consistently requires visual aids and modeling to participate in activities

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Requires adaptive equipment to participate in activities

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Responds to incentive/reward programs

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Sensitive to others touch

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Can manage his/her anger when upset

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Communicates personal needs

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Cooperates w/staff and peers; shares

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Stays with assigned group with minimal supervision

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Becomes frustrated during recreation activities

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Learns best with visual cues

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Maintains personal space

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Requires redirecting and prompting to attend to tasks

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Can stay on task for

minutes

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Reminder: Leisure coaching IS A LIMITED RESOURCE. Transitional

support into support FCPA camps/classes is based on availability and need.

The maximum level of support is generally 3 days of camp during a given

week and should not be construed to serve as 1:1 support (they often support

multiple kids). Classes maintain some flexibility based on the progress of the

customer. If additional support is needed in a camp or class to help meet the

code of conduct, parents, under the ADA, may provide their own support (self,

therapist, aide, babysitter, etc.).

***Effective Mid-August through Labor Day: Camp access to leisure coaches

is generally non-existent. Leisure Coaches (teachers, instructional assistants,

and college students) generally return to school during that time frame. ADA

accommodations and an accommodation plan are provided for the camp

staff/customer***

Customer Profile Page 2

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