Adult Day Program Application

New Learner Application

Please provide your information below and a representative from Behavioral Learning will reach out soon with next steps.
Learner/Client Name

First NameLast Name
Date of Birth

MonthDayYear
Preferred Pronoun
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Learner/Client Phone Number

Area CodePhone Number
Learner/Client Email
example@example.com
Emergency/Guardian Name

First NameLast Name
Emergency/Guardian Number

Area CodePhone Number
Emergency/Guardian Email
example@example.com
Do you authorize communication via text?
If you are the legal guardian and applying for a learner on their behalf, please upload a copy of your letter of guardianship below, to provide proof of guardianship.

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Over the past 6-months, how often do you, or your learner, struggle with or experienced any of the following challenges?

	Not at all-0	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
10. Panic attacks, or feeling so paralyzed you cannot move
11. Avoiding responsibilities
12. Use substances (e.g., alcohol, marijuana, etc.), either to pass time or to better manage your symptoms

How difficult have the above experiences made it for you, or your learner, to do your/their work, take care of things at home, or get along with other people?

	1	2	3	4	5

1 is Not difficult, 5 is Very difficult

What are you, or your learner's, current coping strategies or activities that you/they have done to feel better or deal with the above-mentioned challenges?
What do you hope to achieve as a part of this program?
Have you/your learner participated in counseling in the past?
If YES, when?
Have you/your learner participated in ABA in the past?
If YES, when?
Are you/your learner taking psychotropic medications?
If YES, write the name(s) below
Name of Prescribing Physician
Have you/your learner ever been admitted to a hospital/facility for psychiatric care?
If YES, include Month/Year
For the health and safety of learners and personnel, and in compliance with both state and federal regulations, Behavioral Learning requires individuals who attend and work on-ground to be fully vaccinated. Please upload proof of your vaccination status (e.g., vaccination card) or a letter outlining your request for a waiver. Your help to stop the spread of Covid-19 is appreciated.

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New Learner Application

Strengths & Challenges