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LifeMAP Programs
Intensive Autism Coach Training
AANE.org
Registration - Adult
For which program are you registering?
LifeMAP
Online Video Coaching
LifeMAP for Teens
WorkMAP
InterviewPREP
CollegeMAP
Practice Interview
Coaching Services for DDS
LifeMAP for Over 50
LifeMAP en Español
DDS Pre-Engagement Coaching
Other
Registrant Information
Your Name
*
First
Middle
Last
Date of Birth
Month
Jan
Feb
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Day
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Year
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Address
Country
*
Afghanistan
Aland Islands
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Guadeloupe
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Address 1
*
Address 2
City
*
State
*
- Select -
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--
Armed Forces (Americas)
Armed Forces (Europe, Canada, Middle East, Africa)
Armed Forces (Pacific)
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
ZIP code
*
Registrant's Email
*
Registrant's Phone
Parent/Guardian/3rd Party Email
Parent/Guardian/3rd Party Phone
I grant permission to contact this 3rd party.
Gender
N/A
Female
Male
Nonbinary
Other
Pronouns
Ethnicity
N/A
White (non-Hispanic)
Black (non-Hispanic)
Hispanic
Native American or Alaskan Native
Asian or Pacific Islander
Other
Are you currently working/in school?
*
Working
In School
Other
Please check all that apply.
What are your living arrangements?
*
I live on my own
I live with my parent(s)
I live with my spouse
Other
Do you drive?
*
Yes
No
Do you have access to a car?
N/A
Yes
No
How did you learn about this program?
Will you or a family member be paying for LifeMAP, or do you anticipate that it will be funded by a third party?
N/A
Myself or a family member
By a Third Party
Third parties include such groups as MassAbility, DDS, NH Voc. Rehab, or a school or corporation.
Diagnosis and Treatment
Do you have any of these diagnoses?
Order
Autism
Autism Spectrum Disorder
High Functioning Autism
Asperger Syndrome
Pervasive Developmental Disorder - Not Otherwise Specified
Attention Deficit Disorder/ADHD
Social Pragmatic Communication Disorder
Non-Verbal Learning Disability
Other Diagnosis
Diagnosis
Diagnosis
Approximate Age at Diagnosis
Approximate Age at Diagnosis
Diagnosis by self/medical professional
Diagnosis by self/medical professional
Name of Other diagnosis (if applicable)
Name of Other diagnosis (if applicable)
Do you have any of these diagnoses?
0
Weight for row 1
Add another item
Do you receive housing/rental support?
- None -
Yes
No
Please indicate any benefits/services you are receiving
SSI
Common Health
MRC
Mass Health
SSDI
DDS
DMH
Other
Please check all that apply.
Are you working with other professionals such as a therapist, coach, case manager, speech therapist, etc?
N/A
Yes
No
Other Service Provider Information
Order
No
Yes
Permission to speak?
Permission to speak?
Name
Name
Role/Area of Specialization
Role/Area of Specialization
Phone
Phone
Email
Email
Goals Worked On
Goals Worked On
Other Service Provider Information
0
Weight for row 1
Add another item
Goals and Interests
Name 1 or 2 things you would like assistance with
*
Order
Name 1 or 2 things you would like assistance with
*
-1
0
1
Weight for row 1
Name 1 or 2 things you would like assistance with (value 2)
-1
0
1
Weight for row 2
Examples: time management, organization work, asking for help from teachers, working in groups, interviewing skills, planning for college, making social connections, etc.
What special interests do you have?
Order
What special interests do you have?
-1
0
1
Weight for row 1
What special interests do you have? (value 2)
-1
0
1
Weight for row 2
History
Conviction will not disqualify any registrant from participating in this program.
Have you ever been convicted of a felony?
*
Yes
No
If YES, explain the number of convictions, nature of the offense(s) and how recently such offense(s) was/were committed
Have you attended a LifeMAP Informational Session?
N/A
Yes
No
Additional Notes
Please enter any other important information about yourself here.
Statement of Truth
I certify that information contained in this registration form is true and complete. I understand that false information may be grounds for not accepting me to participate or for immediate termination of participation in this program. I authorize the verification of any or all information listed above.
Client Signature
*
Please type your name to indicate that you agree to the statement of truth above.
Are you currently under guardianship of any kind?
*
No
Yes
Signature of person completing registration
If the person completing this registration form is not the client, please type that person's name to indicate that they agree to the statement of truth above.
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