Collage Arts Program
Application
Today’s Date:
*
-
Month
-
Day
Year
Date
Choose one class option:
*
Visual Arts
Music
Dance
Yoga Only
Yoga & Visual Arts
Yoga & Music
Yoga & Dance
How many classes a week do you wish to attend?
One class per week
Two or more classes per week
Participant’s Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Race (Select all that apply):
*
African American/Black
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino
Middle Eastern
Native American
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant’s Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Participant’s Email:
*
example@example.com
Participant’s Preferred Method of Contact:
*
Please Select
Phone Call
Text
Email
Health Insurance Provider:
*
Please Select
WellCare
Aetna
Anthem
Passport Health
Humana CareSource
Other
Member Number/ID
T-Shirt Size:
*
Please Select
Small
Medium
Large
X-Large
2X-Large
3X-Large
How did you hear about Collage?
*
Please Select
Case Manager
Counselor
Family
Friend
Social Media
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Current Medical History
Please select all that apply:
*
ADD/ADHD
Aphasia/Dysphagia
Apraxia/Dyspraxia
Asthma
Auditory Processing
Autism/Aspergers
Down Syndrome
Cystic Fibrosis
Cerebral Palsy
Developmental Delays
Dyslexia
Hearing Impaired
Learning Disabilities
Neurological Disabilities
Seizure Disorder
Visual Impairment
None of the above
Please list any health issues not shown in previous question:
Please list all known food/medication allergies:
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Sensory Needs
Loud noises bother me.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes loud noises bother me.”
High pitched noises bother me.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes high pitched noises bother me.”
Certain smells really bother me.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes certain smells really bother me.”
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Managing Emotions
My moods change very quickly, sometimes for no apparent reason.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes my moods change very quickly, sometimes for no apparent reason.”
I am comfortable receiving mental health services.
*
Yes.
Sometimes.
No.
Please elaborate if you selected “No, I am not comfortable with receiving mental health services.”
I can easily get upset.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I can easily get upset.”
I get overly upset by certain thing or situations.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I get overly upset by certain things or situations..”
I can be calmed down easily.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “No/Never” to “I can be calmed down easily.”
I stay upset for long periods of time.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I stay upset for long periods of time.”
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Transitioning
I struggle with transitioning from one thing to another.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I struggle with transitioning from one thing to another.”
I struggle when my daily routine is interrupted.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I struggle when my daily routine is interrupted.”
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In the Classroom
I have difficulty staying focused in a classroom setting.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I have difficulty staying focused in a classroom setting.”
I have difficulty working in groups.
*
Yes.
Sometimes.
No/Never.
Please elaborate if you selected “Yes” or “Sometimes I have difficulty working in groups.”
What type of learner are you?
*
Visual Learner
Auditory Learner
Hands-on Learner
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Mental Health Questionnaire
Have you ever received counseling services?
*
Yes.
No.
If currently receiving counseling services, please list it below. (If not applicable please enter N/A)
*
Do you have a hard time sleeping at night?
*
Yes.
No.
Do you have problems making friends?
*
Yes.
No.
Do you have self-esteem issues?
*
Yes.
No.
Do you have difficulty respecting personal boundaries of others?
*
Yes.
No.
Do you become anxious or worry frequently?
*
Yes.
No.
Do you feel sad or depressed frequently?
*
Yes.
No.
Have you experienced a significant change in appetite (eating more or less)?
*
Yes.
No.
Have you experienced a significant change in your sleeping pattern?
*
Yes.
No.
Do you have difficulty maintaining proper hygiene?
*
Yes.
No.
Do you think/talk about, or participate in self-harm behaviors?
*
Yes.
No.
Do you think/talk about, or try to hurt others?
*
Yes.
No.
Do you experience episodes of substance abuse?
*
Yes.
No.
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Caregiver Information
Your Name (If different from participant):
First Name
Last Name
Relation to Participant:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact:
*
Please Select
Phone Call
Text
Email
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Relation to Participant:
*
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Release of Liability:
Signature
*
Submit
Should be Empty: