Request for possible employment

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Thank you for taking the time to complete this form. Please note that this is not a job application.
The questions in red bold lettering are required and you must provide that information.


First Name Last Name
Address Line 1
Address Line 2
City State
Zip Email
Day Phone Evening Phone
example: (301)123-4567 ext.1234 example: (301)123-4567 ext.1234
Best time to call
How did you learn about us?

What position(s) are you applying for?
Check all that apply.
Family Trainer
Supervisor
Intensive Individual Support Technician
Respite Care Worker
Adult Life Planner
Therapeutic Integration Technician

When Can You Start?

How far can you commute to work? 5 miles
10 miles
15 miles
20 miles or more

What is the highest level of education? GED
High school diploma
Some college
AA Degree
BA Degree
BS Degree
Some Graduate School
Masters Degree
Doctoral Degree

If you have a Masters or PhD, what is your field?
Check all that apply.
Education
Child Studies
Psychology
Social Work
Nursing
Occupational Therapy
Speech/Language Pathologist
Other, please specify:

Do you have professional certifications?
Check all that apply.
Psychologist
Special Educator
Speech Therapist
Behavioral Analyst
Other, please specify:

Do you have professional licensures?
Check all that apply.
Psychologist
Social Worker
Nurse Psychotherapist
Speech Therapist
Professional Counselor
Marriage and Family Therapist
Occupational Therapist

What time frame best describes your total amount of experience supporting/serving children/teens with autism? CHOOSE ONE...and be sure the length of time of your experience can be documented. No experience
Less than 3 months
3 to 6 months
7 to 9 months
10 to 12 months
1 to 2 years
3 to 4 years
5 to 9 years
10+ years

Which category(s) best describes your current or past experience involving Children with Autism or Developmental Disabilities (Click all that apply) I have experience as a Professional (certified special education teacher, licensed speech therapist, behavioral specialist, psychologist, etc.) in public and/or private school

I have experience as a Supervisor of Direct Care Staff, as a Professional

I have experience in Writing Treatment Plans or goals and designing implementation strategies for a children with autism or with developmental disabilities in a professional role

I have experience as a Paraprofessional, as a teacher’s assistant or one-to-aide in a special education class room or an inclusive school setting in a public and/or private school

I have experience as a direct care worker at a Residential facility

I have experience as a Parks and Recreation support technician who serves children with autism or with developmental disabilities

I have experience as a Bus Aide (employed by a school or rehab program) providing one-to-one support to children with autism or with developmental disabilities

I have experience as a Day Care Worker who cared for children with autism or with developmental disabilities

I have experience as a Respite Care Worker for children with autism or with developmental disabilities

I have experience as a Baby/Child Sitter caring for children with autism or with developmental disabilities

I have experience as a Home- and Community Based Program Technician hired by an agency and I provided one-to-one support to children with autism or with developmental disabilities

I have experience as a Home- and Community Based Program Technician hired privately by a family and I provided one-to-one support to children with autism or with developmental disabilities

I have experience as a Professional directing older adolescents/adults through the Transition Process in order to access Adult Services in conjunction with service coordinators and the Department of Developmental Disabilities

I have experience as a Supportive Employment Technician or Job Coach who provided direction to an individual with autism or other developmental disabilities

I have experience as a direct care worker who worked for Another Autism Waiver Provider

I have experience as a Volunteer Worker serving children who have autism spectrum disorders or developmental disabilities

I live/have lived with a Family Member who has an autism spectrum disorder or other developmental disability

I have at least 25 hours of College Credits related to autism spectrum disorders or developmental disabilities

In addition to or instead of what is listed above, I Have Other Type(s) of Experience with a children with autism or with developmental disabilities which I will describe in the comment box “Tell Us About Yourself” at the end of this skills profile.

None of the above categories apply to me


If you have a
“special skills” certificate,
What is it?
Check all that apply.
First Aid
Infection Control
CPR
Medication Administration
Training in Seizure Management
Behavior Principles and Strategies
Managing Difficult Behaviors
Other, please specify

What were/are the ages of children with autism you have provided services to? Check all that apply. 5-8 yrs old
9-12 yrs old
13-15 yrs old
16-18 yrs old
19-21 yrs old
None of the above

What were/are the ages of children in general you have provided services to? Check all that apply. 5-8 yrs old
9-12 yrs old
13-15 yrs old
16-19 yrs old
19-21 yrs old
None of the above

What special skills for autism programming have you received training in? Sign Language
Picture Exchange Communication System (PECS)
Augmentative Communication
Facilitated Communication
Floor Time
Relationship Development Intervention (RDI)
Lovass Programming
Discrete Trials
Applied Behavioral Analysis (ABA)
Verbal Behavior (ABBLS)
Natural Environment Learning (NET)
Use of a Behavior Intervention Plan
Functional Behavior Assessment (FBA)
The TEACCH Program
Pivotal Response Theory (PRT)
Social Communication Emotional Regulation and Transactional Supports (SCERTS)
Not Sure
None
Other, Please specify:

Tell us about yourself and explain why you believe you would be an asset to The Whole Self Center.