There are 10 possible sections below to fill out. Please fill out all areas that apply. Much of the information is setup as checkboxes. You can type in Y for Yes for that.

To avoid errors please email the filled in word document. Email to buildingblocks@jewishpress.com. You can also fax it to 347-342-3152.

They are:

1) Contact Information

2) Early Intervention approved programs (Ages birth to 3) __

3) CPSE Schools or Centers (Ages 3-5) __

4) CSE Schools or Centers (Ages 5-21) __

5) Therapy and Evaluation Services __

6) Camps __

7) Day Habilitation __

8) Residences __

9) OPWDD and other programs __

10) Advocacy __

11) Other __

1) Contact Information

Name of organization, school or camp: ___________________________________

Address: ________________________________________________________

Phone: _____________________

Website: ______________________

(These next 2 questions are for follow up purposes only)

Name of person completing this form_______________________

Contact#_________________

2) Early Intervention Approved Programs

Home Based __ Center Based __

ABA ___Floor Time __ Sensory Integration __ MEDEK __

Other (Please specify) ___________

Other services offered such as family counseling, play therapy, music therapy, parent support groups etc ___________________________________________________

3) CPSE Schools or Centers

Home Based ___ Center Based ___ Will send providers to private schools ___

State Approved ___ Privately Funded __

Population Served (Please check those that apply:)

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___

ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Please check the following services provided:

SEIT ___ OT ___ PT ___ Speech ___ Play therapy/counseling ___

What special training or services do you offer children?

ABA ___ Floor Time ___ Sensory Integration ___ MEDEK ___

Other (Please specify) ________

Bilingual Staff If yes list language(s)?_______________________________

4) Schools - School Age (CSE 5-21)

State Approved ___ Privately Funded ___

Population Served

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___

ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Ages Served _________ Boys ___ Girls ___ Separate classes ___ Mixed classes ___

School Hours: _______________ Handicap Accessible ___

Bilingual Staff If yes list language(s)?_______________________________

Services offered:

ABA ___ Floor Time ___ Pre-Vocational ___ Other (Please specify) ____________

Are therapies provided on site? ___ List therapies provided _______________________________

Breakfast provided ___ Lunch provided ___ Meals Kosher ___

Is transportation provided? ___

Is transportation private ___ or through the Department of Education ___?
..

5) Therapy and Evaluation Services

Home Based ___ Center Based ___ Will send providers to private schools ___

Ages Served ________________

Accept RSA's ___ Accept P3s ___ Accept Insurance ___

If yes, please list which insurances are accepted: ____________________________

OT ___ PT ___ Speech/Language ___ Special Ed ___

Do you conduct private evaluations? ___ Other Services ______________________

Handicap Accessible ___ Bilingual (list languages)_____________

Population Served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___

ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Services offered:

ABA ___ Floor Time ___ Sensory Integration ___ MEDEK ___

Other (Please specify) __________________________________________

6) Camps and End of Summer Programs

Duration, # of Weeks _______ Day camp ___ Sleep away camp ___

Location of Camp: ____________________________________________

Ages Served: ______________ Male ___ Female ___ Separate ___ Mixed ___

Population served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___

ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Is special education and related services (therapy) provided on site? _____________

Handicap Accessible ___ Kosher food provided ____ NY State Approved ___

Do you accept children who are not toilet trained? ______

7) Day Habilitation

Ages ___ Group Size ____ Male ___ Female ___ Separate ___ Mixed ___

Center Based ___ DayHab Without Walls ___ Program hours: __________

Are vocational services offered? _____

Population:

_____Mild to moderate developmental delays

_____ Moderate to severe developmental delays

Handicap Accessible ___ Kosher food provided ___ Transportation provided ___

8) Residential opportunities:

Ages Served _________ Male ___ Female ___

Population Served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___

Do you have accommodations or specialization to serve the following populations?: Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

IRA's ___ Supportive Apartments ___

9) OPWDD and other programs

A) Medicaid Waiver __

B) Family support services __

Does your agency offer support groups/services to parents? ____ Siblings? ___

C) Respite ___

D) Overnight respite ___

E) Sunday Program ___

Ages served______ Male ___ Female ___ Separate ___ Mixed ___

Population served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Handicap accessible? ____ Provide transportation? _____

Is there a fee for your program? _____ Provide kosher food? _____

Do you take children who are not toilet trained? ______

F) After School Program ___

Location: _______________________________________________

How may days a week? __________ Ages served______

Male ___ Female ___ Separate ___ Mixed ___

Population served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped ___

Handicap accessible? ____ Provide transportation? _____

Is there a fee for your program? _____ Provide kosher food?_____

Do you take children who are not toilet trained? ______

G) Recreation ___

Ages served __________ Male ___ Female ___ Separate ___ Mixed ___

Population served:

Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___

Visually impaired ___ Multiply handicapped __

How often does your program take place? _____________________________

Where does your program take place? _________________________________

Handicap accessible? ____ Provide transportation? _____

Is there a fee for your program? _____ Provide kosher food? ____________

Do you take children who are not toilet trained? ______

Is your program open to families (parents and siblings) as well as special children_____________________

10) Advocacy

Region(s) served______________________

Do you provide assistance/representation to parents at:

IEP Meetings ___ Impartial Hearings ___ Appeals ___

11) Other Services

For services that don't fit in categories above. Geared towards agencies and organizations that don't apply at all to above categories.

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