Circles Application

Name:
Email Address:
Your daytime phone number
Select Session:	Add me to the wait list and/or notice of next session for children (8-12 years old) with high functioning autism. Add me to the wait list and/or notice of next session for youth and young adults (13+).
Child Name
Child's Age
What is your child's primary and other special needs?
Share with us your child's approximate level of social functioning:	Pre-K Early Elementary Late Elementary Adolescence Young Adult
Tell us about your child's experience with group activities:
List behavioral concerns that need to be considered to ensure your child's safety:
How can PHP provide your child the most positive learning experience?
List any aversions your child may have:
What motivates your child?
Share any other information that will assist us in better reaching your child.
Please advise us of any health issues, food allergies,etc.:
Are there any family circumstances of which we should be aware?
When you submit, you will be routed to the Online Orientation. From there you will be routed to pay online. If you are requesting Regional Center funding for this class, be sure to let us know.