STUDENT APPLICATION QUESTIONNAIRE

    How did you hear about the Zsido Ranch?

    Where and with whom does the applicant now live?

    Current school placement and/or program?
    When is placement needed?

    Primary Diagnosis:

    Secondary Diagnosis:

    Seizures?
    YesNo
    If yes, please describe:

    Current medications/Dose/Reason(s) for Use:
    Current or past therapies:

    Education history and experiences:

    Describe self-care skills and needs:

    Communication skills and needs (speech, hearing, vision):

    Relationship to others, social skills and needs:

    Relationship with children—Can the applicant live and be around small children?

    How does the applicant feel about animals—pets, bugs, farm animals?

    Enjoy participation in group activities?

    Describe level of sexual awareness including behavior disorders or problems, if any:

    Has the applicant been assessed for ability to consent to a relationship?

    Relation to work (work interests, attitudes and habits, work tolerance, skills and limitations):

    Response to direction when undertaking tasks?

    Describe any hobbies, strengths, interests, special abilities, talents and free time activities:


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