Social Circles Program
Please see the enclosed information and
application for more information.
Circle One: Fall/Spring
Year: _________
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The Baylor Autism Resource Clinic Social Circles Program
Baylor University graduate students in the School Psychology program
will provide social skills lessons to selected participants under the
supervision of Kristen Mainor, Ed.S., Licensed Specialist in School
Psychology and Dr. Julie Ivey-Hatz.
One-hour sessions will be provided once per week to each child at the
Baylor Clinic for Developmental Disabilities (BCDD) located at the
Hillcrest MacArthur Clinic at 2201 MacArthur Drive, Suite 101, Waco,
TX 76708. Baylor University campus closings and holidays will be
observed. Please note that this program is NOT intended to replace
school services, but instead to supplement programs that the child may
be receiving.
Goals will be selected by parent/caregiver, and progress monitoring
results will be provided.
Applicants must have a diagnosis of a developmental disability,
including, but not limited to autism, PDD-NOS, or Rett Syndrome. The
program has limited openings.
Applications will be reviewed, and accepted applicants will be placed
with an available group or on the waitlist on a first come, first serve
basis. Participants will be notified of acceptance and/or placement after
application review.
Cost: $25 registration fee**
$25 supply fee**
$10 per session fee
**Fees subject to change
For more information, contact
autism@baylor.edu
(254) 537-1042
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Application Instructions
The following documents must be complete:
 Application
 Parental/Legal Guardian Release (for minor participants only)
 Medical Information & Release
 Confidentiality Protection Form
Applications may be submitted by email, fax, or mail.
Baylor Autism Resource Clinic
Baylor University Center for Developmental Disabilities
2201 MacArthur Dr. Suite 101
Waco, TX 76708
bcdd@baylor.edu
Phone: (254) 537-1042
Fax: (254) 224-6633
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Circle One: Fall/Spring
Year:______
Baylor Autism Resource Clinic (BARC) Social Circles Program Application
Participant’s Name:
(LAST)
(FIRST)
(MIDDLE)
(LAST)
(FIRST)
(MIDDLE)
(STREET)
(CITY)
Guardian’s Name:
Address:
Gender:
(STATE)
_ Ethnicity:___________ Date of Birth:
(ZIP)
Grade Level (if applicable):
(MM/DD/YYYY)
Parent/Caregiver Phone Number (cell phone, if available):
Home Phone Number:
Work Phone Number:
Parent/Guardian Email:
Diagnosis:
Participant Lives with:
Mother & Father
Mother
Father
Other/Legal Guardian (please specify):
List other children in the household:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
How did you hear about the Social Skills program?
Which days of the week and times do you prefer for your child to attend? Please note that daytime appointments are
available and highly encouraged.
Identify participant’s favorite foods, activities, items, etc.:
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Please identify participant’s current skill level. Check one:
Adaptive Behavior Skills:
Independent
Needs Reminders/Instruction
Needs Physical Assistance
Toileting
__________
__________
__________
Hand Washing
__________
__________
__________
Dressing
__________
__________
__________
Communication Skills (check all that apply):
No Speech sounds
Babbles (non-words)
Says 1 – 10 recognizable words
10+ 1-word phrases
2 – 3 word phrases
Short sentences or more
Imitates words & sounds
Echolalia (nonfunctional repeating of sounds)
Primary mode of communication is verbal language
Primary mode of communication is sign language. If yes, approximate number of signs:
Primary mode of communication is pictures/PECS. If yes, approximate number of pictures:
Primary mode of communication is electronic communication device. If yes, approx. # of buttons:
Challenging or Problem Behaviors of Concern (list and rate):
1. _________________________________________________
Mild
Moderate
Severe
2. _________________________________________________
Mild
Moderate
Severe
3. _________________________________________________
Mild
Moderate
Severe
4. _________________________________________________
Mild
Moderate
Severe
5. _________________________________________________
Mild
Moderate
Severe
6. _________________________________________________
Mild
Moderate
Severe
7. _________________________________________________
Mild
Moderate
Severe
8. _________________________________________________
Mild
Moderate
Severe
Identify current therapies the participant currently receives.
Identify and describe five high-priority goals that you would like to see your child meet during Social Circles.
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OPTIONAL: Describe any unique financial needs that influence your child’s need for the Baylor Autism Clinic’s
services.
What portion of the service fees would you be able to pay? _____________________________________________
Applications may be submitted by email, fax, or mail.
If selected, fees and all required forms will be due by the first day of Social Circles. An individualized
fee schedule will be created for participants that choose to pay for sessions on a monthly basis.
Baylor Autism Resource Clinic
Baylor University Center for Developmental Disabilities
2201 MacArthur Dr. Suite 101
Waco, TX 76708
bcdd@baylor.edu
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