Date of your scheduled tour
Tour Date
I understand that I must contact Mainspring Academy immediately by phone or email if I will be late, if I must reschedule, or if I must cancel my tour. I understand after a 10-minute grace period, late arrivals will result in immediate cancellation of my tour. I understand the School will not be able to accommodate any additional parent schedule changes after two instances of cancellations, two instances of rescheduled tours, or any instances of no-call, no-shows. I understand that these requirements are also applicable in the event that I choose to schedule an observation for my child after my tour.
Student Information
Child’s Name (First and Last)
Date of Birth
Date of Birth
Sex
Current Diagnosis
Please list your top concerns
If your child engages in any problem behaviors, please list them here
School Information
Current School
Grade Level
Please list the academic skills that your child is currently working on
Does your child have a current IEP?
Yes
No
Is your child eligible for any state-funded scholarships?
Yes
No
If YES, have you begun the application process?
Yes
No
Please list the state-funded scholarship (if known)
What is your child’s Matrix score (if known)?
Document Upload
A copy of your child's IEP will be required by the date of your scheduled tour to help us better understand how they perform as a student. If your child does not have an IEP, a copy of their psychological evaluation will be required. Please upload your documents below.
IEP
Psychological Evaluation
Family Information
Parent/Guardian Name(s) (First and Last)
Relationship
Email Address
Phone Number
Parent/Guardian Name(s) (First and Last)
Relationship
Email Address
Phone Number
Home Address
How did you hear about us?
New Student Parent Questionnaire
Please fill out the below survey as accurately as possible. This survey will be used to determine appropriate classroom placement and support needed. The survey will not determine a child's eligibility as a student at Mainspring Academy.
1. Fidgets or squirms in seat
2. Is restless or overactive
2. Is restless or overactive
4. Runs or climbs when he/she is not supposed to
5. Inattentive, easily distracted
6. Is impulsive, acts without thinking
7. Requires assistance to engage in social interactions with peers
8. Has difficulties generalizing skills across settings
9. Can work independently on an academic task for 15 minutes
10. Can work independently on an academic task for 30 minutes
11. Is hard to motivate, even with rewards like candy or a preferred toy
12. Requires redirecting to complete tasks
13. Requires assistance to transition within the building
14. Requires assistance to transition when outside
15. Requires assistance to complete self-care skills (Ex. Brushing teeth, combing hair, washing hands, etc.)
16. Has a difficult time regulating his/her emotions
17. Avoids social interaction
18. Avoids others, prefers to be alone
19. Bullies others
20. Threatens to hurt others
21. Starts fights with others on purpose
22. Needs an extra explanation of instructions
23. Has trouble getting started on tasks or projectsan extra explanation of instructions
24. Has a short attention span
25. Has trouble concentrating
26. Requires prompting to respond to questions
27. Speaks in phrases
28. Uses an augmentative communication device to communicate
29. Has tantrums
30. Intentionally disobeys and defies those in authority
31. Is physically aggressive (Hits, kicks, bites, etc.)
32. Runs away from designated area
33. Throws or destroys items
34. Engages in self-injury
35. Has eating difficulties (eats too fast or slowly, hoards food, overeats, refuses to eat, steals food from others, etc.)
36. Has tics (involuntary blinking, twitching, head shaking, etc.)
37. Swears
38. Ignores or doesn't pay attention to others around him/her
39. Engages in inappropriate sexual behavior
40. Is obsessed with objects or activities (repetitive words or phrases, is preoccupied with mechanical objects, etc.)
41. Expresses thoughts that do not make sense (talks about hearing voices, seems delusional, etc.)
42. Has strange habits or ways (repetitive noises, odd hand movements, etc.)
43. Engages in self-stimulatory behaviors (hand flapping, rocking, etc.)
44. Is unusually fearful of ordinary sounds, objects, or situations
45. Requires PRN medication dispensing at school
46. Requires daily medication dispensing at school
47. Requires monitoring of health needs
Thank you
Student Behavior Profile
1. What are the behaviors of concern? For each, please define how the behavior is performed, how many times it happens per day/week, how long it lasts, and the intensity in which it occurs (low, medium, high)
BEHAVIOR 1 (Ex. Hand biting)
Behaviors1HowPerformed
Behaviors1HowOften
Behaviors1HowLong
Behaviors1Intensity
BEHAVIOR 2 (Ex. Hand biting)
Behaviors2HowPerformed
Behaviors2HowOften
Behaviors2HowLong
Behaviors2Intensity
BEHAVIOR 3 (Ex. Hand biting)
Behaviors3HowPerformed
Behaviors3HowOften
Behaviors4HowLong
Behaviors4Intensity
2. Do any of the above behaviors occur together?
3. Are there any situations that may trigger the above listed behaviors? (Ex. Being told to take a bath, having the iPad taken away, etc.) Does your child have any medical complications that may impact their behavior? (Ex. Headaches, asthma, etc.)
4. Describe the sleep cycles of the child and the extent to which sleep impacts behavior or school performance
5. Describe the eating habits of the child and any challenges that you may have with eating (Ex. Food selectivity, overeating, swallowing, vomiting, etc.)
6. List the child’s preferred leisure activities. Please also list any problem behaviors that may occur during leisure activities
7. List the child’s tangible reinforcers (Ex. Specific foods, devices, toys, characters)
8. Does your child have any restricted interests, OCDs, or stims that impact their ability to participate in school or home activities? Please list.
9. How does your child communicate? (Speech, gestures/pointing, sign, communication device, writing, etc.)
10. Where is your child with toileting? (Ex. Fully independent, has accidents, in pull-ups, etc.)
11. Does your child have any behaviors that make you concerned for their safety? (Ex. Elopement/ running away, self-injury, sexual behavior)
12. How does your child socialize? Do they prefer peers or adults? Do they enjoy interactive play or would they rather be alone?
13. Please list 3 primary goals that you have for your child at school
Submit
