Home - Shaurya Foundation

Assessment/Intake- Form Independent Living Program

STUDENT’S DETAILS

Name of the Student

Date

Date of Birth

Gender

Age

Present Institute

Present Challenges

Section 1

Has ever stayed alone in day time at home without parents alone

Has ever stayed alone over night at home without parents and siblings

Has ever stayed alone over night at home without parents and grandparents

Has ever stayed at relatives’ home without parents

Has ever been to any trip out for overnight stay without parents

Has ever traveled by road or other mode of transport without parents

Is prone to motion sickness

Enjoyed the overnight camp stay

Is able to look after his own belongings

Is aware of basic safety issues

Medicine Schedule

Section-2

Daily Routine

Kindly share the details of the daily routine of your child at home -

Morning Routine

Like to drink

Toileting

Kindly provide details

Close the door while inside the toilet

Can pull down the pant

Can wash himself after big job

Can flush the toilet after use

Can pull up his pants after cleaning

Can wash hands with soap after use

Use toilet schedule

Brushing

Brush his teeth on his own/ or need reminders

Kindly provide detail

Can apply toothpaste appropriately

Can use the correct strokes for brushing

Can rinse mouth after brushing teeth

Can use tap/ mug/glass

Complete the task in given time

Bathing

Have Bath on his own or/ need reminders

Kindly provide details

Can take the required items to the bathroom (shampoo/soap/towel/clothes)

Can use the bucket and mug or /shower appropriately

Can apply soap properly

Can apply shampoo properly

Can wash off soap and shampoo properly-

Can wipe him off with towel appropriately

Complete the task within time

Prefer to use

Likes to play with water while bathing

Undressing and Dressing

Undress and Dress himself

Kindly provide details

Undressing

While undress, he closes the room

Can remove upper and lower garments both

Can reverse the clothes

Can put dirty clothes away in basket

Can pull off belts

Can pull off shoes

Can pull off socks

Can place the shoes in the shoe rack

Dressing

Can take out undergarments and clothes from the almirah

Can wear undergarments appropriately

Can wear lower garments appropriately

Can wear upper garments appropriately

Can put on belts

Can put on socks

Can put on shoes

Grooming

Groom himself

Kindly provide details

Can wash his face properly

Can apply-deodorant/ talcum powder/ moisturizer or cream/ hair oil

Looking Self in mirror

Meal Routine

Kindly share details

Meal Time

quantity / portion needed

any specific instruction

Eating & Drinking

Eating & drinking

Kindly provide details

Wash hands before meal

Can serve food for himself

Can have meal without spilling

Can use hands/spoon/ fork properly

Can chew the food properly

Can finish the meal in given time

Night Routine

Sleeping time

Number of hours of sleep

Habits before sleeping

Sleep with

Sleep

Wakes up for washroom

Specific Allergy – if any

Food

Milk

Water

Soap

Dust

Any Other

Section-3

Cognitive Skills

Reading

Can sight read or read -two/ three/ four letter words in context

Understands the context while listening to others reading orally

Recognizes/sight read and uses task/work-related words, abbreviations, acronyms, and codes

Can identify/ sight read factual information related to work/family/self

Follows procedures and directions to complete a task/ work

Can identify and locate basic information for the work

Can scan text or manuals and identify/sight read the relevant information or clue words

Can sort and arrange work related and personal documents and objects

Can interpret simple codes and symbols and use them appropriately

Writing

Can write name, address and telephone number on paper / computer

Can write a basic sentence on paper/computer

Knows how to use the keyboard to write letters and papers

Knows how to use spell check programs on the computer

Knows how to look word up in the dictionary to find the correct spelling

Mathematics

Can count and write numerals 0 to 10

Can count and write numerals up to 100

Can write numbers in written word form

Can read, write, and count single/ double/ multiple whole digits

Can add, subtract, multiply, and divide single/ double/ multiple digit numbers on paper/with calculator/ mentally

Uses addition, subtraction, multiplication, and division to solve problems on paper /with calculator /mentally

Understands simple fractions or /equal sharing/dividing and can use them in real life situations

Understands weight and measurements and can use them in real life situations

Can use and sight read/read charts, tables, and graphs

Can scan and find the relevant information on charts, tables, and graphs

Can distinguish between relevant and irrelevant information on charts, tables, and graphs

Can make a simple chart, table and graph on paper/computer

Problem Solving

Classifies and matches objects by colour/size/or significant markings

Can ask for help when needed to solve problem as a team

Can offer help to others

Can summarize information

Use various sources of information

Recognize cause and effect relationship

Can draw conclusion

Can predict outcome

Can identify and choose alternative strategies when needed

Can identify and use tools and resources for the task/work

Can make decisions

Section-4

Communication

Understands verbal directions

Can follow verbal directions

Understand commands in smaller steps

Can demonstrate or vocalize needs and wants (speak, write, sign or use a communicator)

Speaks clearly and politely

Speaks or communicates at a rate easily understood by others

Speaks or communicates at an appropriate volume

Does and will listen to advise, and will accept assistance

Listens to learn and for understanding

Verifies understanding by restating or repeating the message

Verifies comprehension by asking questions

Knows how and can use the telephone appropriately in various situations

Sensory Profile

Has sensory challenges

Tactile

Does messy play

Play with rough texture/surface

Likes to touch wet items

Likes to wash hands after touching wet objects

Likes to touch granular items

Wear clothes of selected texture

Doesn’t like to wear woolens

Doesn’t like to be hugged/kissed/ touched

Doesn’t like to touch his head

Doesn’t like to have hair/nail cut

Likes to play with water

Doesn’t like to put soap/gel

Doesn’t like to wear slippers/sandals/shoes

Play with food

Play with his own feces

Likes to feel heat or steam or air on face or hands

Auditory

Close his ears/ hit himself in noisy environment

Make sounds to cut him off from noisy environment

Listens music with close proximity

Have selected choice of music

Screeching sounds/ high pitch sounds disturbs

Doesn’t want to have hair cut because of scissors sound

Can’t take too many instructions

Likes to have vibrations

Olfactory

Likes to smell everything

Likes to smell food

Gets irritated with certain smells

Doesn’t like scented products

Visual

Likes to see free flow things/prints

Like to watch glossy objects

Likes to watch spinning objects

Likes to watch thing in sequence

Likes to watch/ have items of certain colour

Likes to watch steam or free flow water or powder

Vestibular

Likes to rock

Likes to spin

Loves to be on swing

Likes to have long car rides

Likes vibrations on his body

Always on the go

Walks on toes

Never stand still

Proprioceptive

Like to be hugged very tightly

Holds others very tightly

Likes to have heavy blanket while sit or sleep

Likes to jump a lot

Likes to play rough and tumble game

Bites himself

Practical Skills

Making Bed

Kindly share details

Knows about pillow/ bedsheet/ blanket

Can place pillows appropriately

Can spread the bed sheet appropriately

Can tuck in the sheets from the edges

Shopping

Kindly share details

Knows/aware of nearby market

Can make list for grocery shopping

Can make list for vegies and fruits shopping

Can identify the items in the shops/ malls

Can read the price and expiry dates

Can read the measurement

Can calculate the total amount – on paper/ calculator/mentally

Can give exact amount only

Can transect money and give and take exchange

Meal Preparation

Has been allowed to explore in kitchen

Can sort the veggies/ fruits/salads and place them appropriately

Can identify all the masala or ingredients used in cooking

Can identify all the utensils and their uses

Can pluck leaves of coriander/spinach/ mint

Can peel boiled potato

Can peel peas

Can peel with knife

Can chop veggies/fruits/salads with chopper

Can chop with knife using chopping board

Knows how to wash veggies/ fruits/salads before chopping and using

Can make lemon water

Can make sandwich without cooking

Can toast bread by using toaster

Can warm water by using gas/microwave/hot plate

Can warm milk by using gas/microwave/ hot plate

Can make tea/coffee by using gas/microwave/ hot plate

Can make Maggie by using gas/microwave/ hot plate

Can make evening snacks using gas/microwave/ hot plate

Can make chapati /parantha using gas/microwave/ hot plate

CCan make dal and chawal using gas/microwave/ hot plate

Can make simple vegetable dry and with curry using gas/microwave/ hot plate

Can do meal planning

Safety and Security

Knows the sign and word danger

Can judge the height/depth and risk in physical space

Has and knows the use of fire extinguisher in kitchen and home

Knows the risk in touching very hot/sharp /or electrical items and use them with safety

Can use first aid when needed appropriately

Can seek medical help if needed

Aware of nearby medical services

Knows the risk in using sharp edge equipment and use them with safety

Knows the risk or running on road-

Knows and follows the rules of walking or crossing on road

Knows and follows the rules of using transport-private/public

Knows the concept of privacy

Shut the door when changes clothes and bathing

Knows who is stranger, who is not

Know not to talk to strangers

Knows the good touch and bad touch

Can seek help while face any risk

Knows whom and how to report

Knows the contact numbers of emergency services

Can dial /recite/ show- the numbers when needed

Can recite/ show -name and address when needed

Can catch the public transport for a predetermined destination

Locks the door while entering and leaving the vehicle

Locks the doors while entering and leaving the house

Aware of evacuation plan in case of fire and earthquake

Money Management

Has a savings account, and understands the value of saving

Knows how to write and sign cheques

Understand how to manage cheque books

Knows how to use ATM machine

Can keep check/ record of balance / withdrawal /deposits in account

Community Living Skills

Can navigate his or her self through town

Knows what services are available and use, if assistance is needed

Knows and visit a doctor and a dentist that is close to home

Has a telephone in home and can use to talk to neighbours /family/ friends

Is a member of a RWA/ religious group / club -close to home and participate

Can commute locally with private vehicle

Can commute locally with public transport

Can buy tickets for self

Can commute interstate with private vehicle

Can commute interstate with public transport

Concluding Remarks

Sign Assessor

Sign Parents

ILP Form

Assessment/Intake- Form Independent Living Program

STUDENT’S DETAILS

Section 1

Section-2

Daily Routine

Morning Routine

Kindly provide details

Brushing

Kindly provide detail

Bathing

Kindly provide details

Undressing and Dressing

Kindly provide details

Undressing

Dressing

Grooming

Kindly provide details

Meal Routine

Kindly share details

Eating & Drinking

Kindly provide details

Night Routine

Specific Allergy – if any

Section-3

Cognitive Skills

Reading

Writing

Mathematics

Problem Solving

Section-4

Communication

Sensory Profile

Proprioceptive

Practical Skills

Making Bed

Kindly share details

Shopping

Kindly share details

Meal Preparation

Safety and Security

Money Management

Community Living Skills

Concluding Remarks