bridge to independence- diploma program … to independence- diploma program admission procedure ......

BridgetoIndependence

1Revised2-1-17

BridgetoIndependence-DiplomaProgramAdmissionProcedureTheBridgetoIndependenceDiplomaprogramatNichollsStateUniversityisanoptionalacademicandsupportservicefordegreeseekingstudentswithAutismSpectrumDisorder(ASD).Criteria

• StudenthasbeenacceptedtoNichollsthroughtheregularadmissionsprocess• Age18-28• StudenthasadiagnosisofAutismSpectrumDisorder(ASD)asindicatedonacurrent

(withinthreeyears)psychologicalevaluation• Personalmotivationforsuccess• Personalaccountability• Opennesstoreceivesupport• Abilitytomaintainpersonalsafety

2Revised2-1-17

STEP#1InitialCriteriaIftheinitialcriteriaaremet,theapplicantmayapplydirectly.Theapplicationinstructionsandformscanbeaccessedonlineatwww.Nicholls.edu/BridgetoIndependenceorbyemailing:Dr.MaryBreaudatmary.breaud@nicholls.eduTheApplicationPacketincludes:•BridgeDegreeprogramApplication•PersonalStatementInstructions•ReferenceLetter(Print2oftheseforms)•ReferenceLetter-Waiverform•AuthorizationtoReleaseStudentInformationform•Applicant’sSkillInventory•GraffParentReadinessScale(GPRS)•ScopeofServicesSTEP#2ProgramTour:TheapplicantandfamilymustattendaBridgeprogramTour.Duringthetour,allaspectsandgoalsoftheprogramwillbereviewedanddiscussed.Atourofthecampusandresidencehallswilltakeplacewithanopportunityforquestionsandanswersbythestaff.ThetoursarescheduledthroughouttheyearandattendingismandatorybeforebeingconsideredfortheBridgeProgram.CalltheNichollsAdmissionsOfficeat985-448-4507toscheduleatour.AdmissionPacket:AllrequireddocumentsmustbesubmittedtogethertocompletetheprocessforadmissionconsiderationtoBridge.ItisimportantthatthemostcurrentinformationissubmittedinordertoascertainthattheBridgeProgramisanappropriateplacementandthatthestudenthasthecombinationofdesire,motivation,skill,andexperiencetobesuccessfulintheprogram.Documentsandcompletedformsrequiredattimeofsubmission:1.BridgetoIndependenceApplication2.Recent5”X7”photograph3.AuthorizationtoReleaseStudentInformationform-signed&dated4.BridgetoIndependenceSkillInventory5.PersonalStatement.Thisistheapplicant’sopportunitytostatereasonsforwantingtoattendBridgeandprovideadditionalpersonalinformation.Becreative!Thiscanbehandwrittenortypedbytheapplicant,aportfolio,videorecordedontoaflashdrive(noDVD/CD’sastheywillcrackinthemailingprocess),etc.Themaximumallowedtimeforvideorecordedpersonalstatementsis5minutes

3Revised2-1-17

8.Current1508specialeducationevaluationorevaluationfromprivateproviderwithfullassessmentdataandexitIEPfromHighSchoolifstudentattendedpublicschoolSubmissionrequirements:•Submitallrequiredmaterialsinonepacket•Allofthematerialsmustbethoroughlycompleted•IncompleteapplicationswillnotbeprocessedSTEP#3OncethecompletedadmissionpackethasbeensubmittedandreviewedbytheBridgestaff,notificationletterswillbemailedtoallapplicants.Theletterwillstateeither:•Theapplicantandparent(s)orguardian(s)willbecontactedtosetupthenextstepintheprocess,whicharetheinterviews,STEP#4–ApplicantswhoareselectedtobeinterviewedTheapplicantwillbeinterviewedseparatelyfromtheirparent(s)/guardian(s).Theinterviewprocesswillascertain:•Thatthestudenthasthedesire,abilityandmotivationtoparticipateintheprogram•Thatthestudent’sindividualneedscanbeappropriatelyservedbytheprogramstaffand/orcommunityanduniversityresources.•Thestudentispreparedtoentertheprogram.•Thestudentmeetstheentrancerequirements.

ResultsNotificationUponcompletionoftheinterviews,notificationwillbesenttoeachapplicantinatimelymanner.Pleasebepatient.Thisisadauntingprocess.Weareweighingourdecisionscarefully.Pleasemailcompletedpacketsto:

BridgetoIndependenceatNichollsStateUniversityAttention:Dr.MaryBreaud,Ed.D

CollegeofEducationP.O.Box2053

Thibodaux,LA70310

4Revised2-1-17

BridgetoIndependenceApplication

To ensure that the application is processed, applicant and/or parent/guardian must complete allinformation(Race&ethnicitytrackingisoptional).

DateattendedaNichollstourandprogramoverview:_____________________

IDENTIFYINGINFORMATIONApplicantName:

Birthdate:

StreetAddress: Age: City: State: Phone: () ApplicantsCellPhone:() Male/FemaleApplicant’sEmailAddress:

Driver’sLicense: Yes/No

U.S.Citizen: Yes/No CountryofCitizenship:

LanguagesSpokenintheHome: AreyouConserved: Yes/NoAreasConserved:

Conservator’sName:

RelationshiptoApplicant:

PARENTINFORMATIONParent#1orGuardianName: Address: EmailAddress: PrimaryPhone# () EmailAddress:

Parent#2: Address: EmailAddress: PrimaryPhone# () CellPhone#:()

SIBLINGINFORMATIONNameofSibling(s) Age LivesatHome

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

5Revised2-1-17

EDUCATION&SERVICES NameofInstitution DiplomaHighSchool: CollegeorProgram:

HighSchoolCompletionorProjectedDate:

SubjectStrengths:SubjectWeaknesses:

DoestheapplicanthaveaLouisianaMedicaidwaiver? Yes/NoIfyes,CaseManagementAgencyName:

Phone#: ()

Address: CaseManager’sName: EmailAddress: Fax#: DirectServicesProvider: Yes/No Direct

ServiceProviderAgencyName:

Address: Phone#: ()EmailAddress: Fax#: ()IsaclientofLouisianaRehabServices:

Yesq Noq InProcessq

Address:

LRSCounselorName: Phone#: ()

Email: Fax#: ()

DoyoureceiveSSI:

Yesq Noq InProcessq Willapplyq

IfYes,NameofPayee: AmountPerMonth: $

6Revised2-1-17

VOLUNTEER&COMMUNITYSERVICE

Organization DescriptionofActivityandDuties Hours/PerWeek

WORKEXPERIENCEBusiness/Organization Duties DatesEmployed Hrs/Wk

7Revised2-1-17

MEDICATIONINFORMATIONDoYouTakeMedication(s): Yesq Noq

NeedsAssistanceWithMedications:Yesq Noq Ifyes,pleaseexplain:

Medication(s) TimesofDay/Week Purpose

8Revised2-1-17

BEHAVIOR

Causedpropertydamageincludingfires YES NOPhysicallythreatenedand/orattackedothers Verballythreatenedothers Self-injuriousbehavior Mistreatinganimals Elopement Lying Fabrication Inappropriatesexualbehavior Stealing Priorarrestorprobation Tobaccouse/abuse Marijuanause/abuse Druguse/abuse Alcoholuse/abuse Seizure(s) Currentgangbehavior,affiliationanddesires Incontinenceproblems Requiresattendantcare Consistentlyfollowsverbaldirections Ifyestoanyofthebehavioralandorself-careissues,pleaseexplainindetail.Includethemostrecentdate(s)oftheoccurrence(s)andseverity(useanothersheetformorewritingspace):

9Revised2-1-17

RACE&ETHNICITYTRACKING

OPTIONALForpurposeofdatacollectionforBridgetoIndependencefunding,pleasemarkthebox9es0thatbestdescribestheapplicant’srace/ethnicitycategoryorwhichhe/sheidentifieswith:A___ AsianorPacificIslander:PersonshavingoriginsinanyofthepeoplesoftheFarEast,

SoutheastAsia,theIndiansubcontinent,orthePacificIslands.Thisareaincludes,forexample,China,Japan,Korea,thePhilippineIslandsandSamoa.

B___ AfricanAmerican(notofHispanicorigin):Personhavingoriginsinanyoftheblackethnicgroups.

H___ Hispanic:PersonshavingoriginsinanyoftheMexican,PuertoRican,Cuban,CentralorSouthAmericanorotherLatinCultures,regardlessofethnicity.

I___ NativeAmericanorAlaskanNative:PersonshavingoriginsinanyoftheoriginalpeoplesofNorthAmerica,andwhomaintainculturalidentificationthroughtribalaffiliationorcommunityrecognition.

W___ Caucasian(notofHispanicorigin):PersonshavingoriginsinanyoftheoriginalpeoplesofEurope,NorthAfricaortheMiddleEast.

IhavecompletedthisBridgetoIndependenceDiplomaprogramapplicationtruthfullyandtothebestofmyknowledgeallinformationisaccurate.ApplicantSignature:_________________________________________________Parent/GuardianSignature:____________________________________________Date:____________________

10Revised2-1-17

PersonalStatementInstructions

Animportantpartoftheadmissionsprocessisthepersonalstatement.ThisisyouropportunitytoshinebytellingwhyyouwanttocometotheBridgeProgramaswellassomethingaboutyou.Thisincludesfactsaboutyourbackground,goals,andanyotherinformationthatyouthinkwillhelpuslearnmoreaboutYOU.BECREATIVE.Thepersonalstatementcanbehandwrittenortyped,aportfolio,videorecorded,etc.Anyelectronicsubmissionsmustbeonaflashdrive,asaDVD/CDwilleasilybreakduringthemailingprocess.Themaximumallowedtimeforvideorecordedpersonalstatementsis5minutes.Materialssubmittedwillnotbereturned.Yourpersonalstatementmustincludenumbers1–4and11below.5-10areoptional.1.Yourname.2.WhyyouwanttoparticipateintheBridgetoIndependenceDegreeprogram.3.Specialinterests.4.Includespecificareasoractivitiesyouwouldlikeparticipateinwhileintheprogram.5.Describe1-2opportunities/tripsyouhavetakenwithoutyourparents/family.Include: •#ofdays •Destination •Purpose(e.g.vacation,conference,etc.) •Howyoufeltaboutbeingaway •Whoyoutraveledwith •Modeoftransportation6.Thingsyouliketodoinyourfreetime.7.Inschool,nameyourfavoritesubject(s)andyourleastfavoritesubject(s).8.Yourstrengths.9.Areasyouwouldliketoimproveupon.10.Describewhatyoulearnedandenjoyedaboutanypaidand/orvolunteerworkexperience.11.Describewhatyouseeasyourideallifeinthefuture? •Wherewouldyouliketowork? •Wherewouldyouliketolive?ACity,Apartment,condominium,homeandwouldyouliketo livewitharoommates,familyoralone.

11Revised2-1-17

CaseManagementStateAgencyReferralForm(ifapplicable)PleasereviewadmissionscriteriabeforereferringyourclienttotheBridgetoIndependenceProgram(Bridge)atNichollsStateUniversity.

Attachthemostcurrentstatereportforthisclient.ClientName:UCI#:Age:Diagnosis:Fax:()Address:NameofServiceCoordinator:Phone#:()Email:NumberofMonthsorYearstheApplicanthasbeenyourClient:ClientName: ID/Case#: AGE: Diagnosis: NameofAgency: Fax#: ()Address: NameofCaseManager: Phone#: Email: Numberofmonthsoryearstheapplicanthasbeenyourclient?: 1.Whataretheclient’smostexemplarytraits?2.Whataresomeareasforimprovement?3.Stateanyfactors/characteristics/behaviorsofthisclientthatwouldbeaconcernforBridge?Pleasebeveryspecific.4.Statereasonswhyyoufeeltheclientisorisnotappropriate/readyforBridgeatNichollsState?

12Revised2-1-17

5.Isyourclientreadytomoveoutofthehouse?Explainwhyorwhynot.6.Doyoufeeltheclient’sparents/guardian,aresupportiveoftheirson/daughterparticipatingintheBridgeDegreeprogram?Explain.7.Generally,howoftenwouldyousaythisclient’sparent’scontactyou?7a.Whenyou’recontactedbythisclient’sparents,whattypesofnegativeorpositivesituationsareyouaddressing?8.Doyoufeeltheclient’srightsandchoicesasanadultarebeingrespectedandsupportedbyhis/herparents/guardians?Pleasegiveexamples.9.Doestheclienthaveastrongsupportsystem?Statewhotheyareandhowtheysupporttheclient.

13Revised2-1-17

Checktheboxforallthatapplytotheclient’shistoryof:_______________________________Causedpropertydamageincludingfires YES NOPhysicallythreatenedand/orattackedothers Verballythreatenedothers Self-injuriousbehavior Mistreatinganimals Consistentlyfollowsverbaldirections Elopement Lying Fabrication Inappropriatesexualbehavior Stealing Priorarrestorprobation Tobaccouse/abuse Marijuanause/abuse Druguse/abuse Alcoholuse/abuse Seizure(s) Currentgangbehavior,affiliationanddesires Incontinenceproblems Requiresattendantcare Resentmenttowardsparent(s) Ifyestoanyofthebehavioralandorself-careissues,pleaseexplainindetail.Includethemostrecentdate(s)oftheoccurrence(s)andseverity(useanothersheetformorewritingspace):

14Revised2-1-17

Certification:Ihavecompletedthisapplicationtruthfully,andtothebestofmyknowledgeallinformationisaccurate.CaseManagementAgencyServiceCoordinator:__________________________________Date:_____________SignatureSubmissionofRegionalCenterReferralForm:Yourclient’scurrentAnnual/QuarterlyreportMUSTbesubmittedwiththisform.ThisreferralMUSTaccompanytheBridgeDegreeprogramapplicationwhenitisreceivedbytheprogram’sofficeforreview.Returnall3documentstoyourclientinanenvelopesealedasdirectedbelow.EnvelopeSealingInstructions:Oncecompleted,pleaseplacethisreferralinanenvelope,sealtheenvelopecompletely,writeyournameacrosstheoverlapoftheflap/envelopebody.Finally,placeagenerousamountofcleartapeoveryoursignature.

15Revised2-1-17

AuthorizationtoReleaseInformation

Name(s)ofAgency,HighSchool,Professional,Medical(allthatapply)

Applicantname: DOB: Today’sDate:

BridgetoIndependenceatNichollsStateUniversityrequeststhefollowinginformationregardingtheaforementionedpersontoaidinprovidingqualityservices:Medicalinformation:

• DiagnosticInformation• CurrentMedications• TreatmentHistory• Assessments/Evaluations

PsychologicalInformation:• Diagnosticinformation• CurrentMedications• Treatmenthistory• Assessment/Evaluations

o IndividualEducationPlan(IEP) o IndividualTransitionPlanforEmployment

o EducationalAssessments/1508Evaluation

o SocialAssessmentInformation

o EmploymentAssessment(LouisianaRehab.Services)

o CaseManagementAgencyReports/Plan

o Other(describe): Bysigningbelow,IunderstandthatBridgetoIndependenceatNichollsStateUniversityshallshareinformationwiththereferringagencyandanyotheragenciesasitpertainstotheprogramservicesrenderedtotheaforementionedpersonandhis/herhealthandwelfare.IauthorizeBridgetoIndependencetorequestinformationfromthereferringagency,schoolandotherpertinenthealthcareprovidersthatisdeemedpertinenttoservicesprovided.IalsoauthorizethereleaseofinformationfromthereferringagencytoBridgetoIndependencetoaidinprovidingsuchservicesonlyuntilIcompletetheprogramorforthreeyearsfromsignaturedate(whichevercomesfirst).ApplicantSignature:_________________________________________Date:________________GuardianSignature:_________________________________________Date:________________BridgeStaffSignature:_______________________________________Date:________________

16Revised2-1-17

ApplicantSkillInventoryApplicantName:____________________________________________________Personassistingorratingapplicant:_____________________________________Relationship:________________________________Date:_________________

UsethisrubrictoratetheapplicantwiththeattachedSkillInventory

WithNoAssistance

Applicantisabletoaccomplishthetaskwithoutassistance

LittleAssistance

Applicantrequires25-50%assistancetoaccomplishthetask

SignificantAssistance

Applicantrequires50-75%assistancetoaccomplishthetask

WithNoReminders

Applicantisabletoaccomplishthetaskwithoutreminders

FewReminders

Applicantisabletoaccomplishthetaskwithreminderson25-50%ofthesteps

ManyReminders

IsStilllearning

ThisparticulartaskisnotapplicabletothisApplicant

PlaceamarkintheappropriateboxindicatingtheLevelofAssistanceANDtheLevelof

Remindersneededtoaccomplishtheskill.Seeexampleonthenextpage.Pleasefollowtheexampleprovidedatthetopofthenextpage.

17Revised2-1-17

Academics:General WithNoAssistance

LittleAssistance

SignificantAssistance

WithNoReminder

FewReminders

ManyReminders

IsStillLearning

Keepstrackofassignmentsandduedates

Bringspropersuppliestoclass Completesmultiplechoiceexams Completeswrittenexams Getsupinthemorningforschool

18Revised2-1-17

WHATARETHISAPPLICANT’SNEEDS?

Whatarethestudent’sstrengthsandtheirareasofneed?Pleasedescribeindetailanypreviouslyusedsupports,accommodations,and/orbehavior/managementplan.Listanytypesofassistivetechnologyutilized.Ifyouneedmorespace,pleaseattachanadditionalpage.

19Revised2-1-17

WHATWOULDANIDEALDAYBELIKEFORTHEAPPLICANT?

Whatwouldanidealdaybelikefortheapplicant?Pleaseincludeallcurrentpertinentrecreationalactivitiesaswellasareasofinterest.Ifyouneedmorespace,pleaseattachanadditionalpage.

20Revised2-1-17

WHATISTHEAPPLICANT’SEDUCATIONALHISTORY?

Pleaselistanyeducationexperiencesthatwillgiveapictureofhowtheapplicantlearnsbest.Whereinschoolwastheapplicantmostsuccessful?Pleaseelaborateonstrengthsandareasforimprovement.

21Revised2-1-17

GraffParentReadinessScale(GPRS)

Thisscalehelpsdeterminethefamilies’readinessforthestudentwithAutismSpectrumDisordertoattendapost-secondaryprogram.

Pleasecirclethefamily/guardian’sresponse.

1=Istronglyagree,2=Iagree,3=Ineitheragreenordisagree,4=Idisagree,and5=Istronglydisagree.

1.Iexpecttoknoweverythingmystudentsdoesattheuniversity.

StronglyAgree12345StronglyDisagree

2.Iexpectone-onesupportallday.

3.Iworryaboutmystudenttalkingtootherstudentsunsupervised.

4.Iworryaboutmystudentcrossingthestreet.

5.Ineedtoknowthehomeworkassignmentforeachclass.

6.Ineedtoknowthecalendarofactivitiesofferedtomystudent.

7.Iwouldliketospeakwithmystudent’ssupportstaff.

8.Iwouldliketoattendclassestoseemystudentinteractwithothers.

9.Itrustmystudent’sjudgment.

10.Itrustmystudent’sabilitytohandlesmallsumsofmoney.

11.Iknowmystudent,withsupport,willdevelopfriendships.

22Revised2-1-17

GraffParentReadinessScale(GPRS)Continued

12.Iknowmystudent,withsupport,willtrynewopportunities.

13.Mystudenthastheabilitytohandlefrustration.

14.Mystudenthastheabilitytoseekassistance.

15.Often,Iamincontactwithmystudentsmorethan3timesaday.

16.Often,Iamtellingmystudentwhattodoandsay.

17.Icheckuponmystudent.

18.Ichecktoseeifmystudenthasthecorrectfacts.

19.Ibelieve,Iknowwhatisbestformystudent.

20.Ibelieveapostsecondaryeducationisimportantformystudent.

21.Ifeelthatmystudentknowswhatisbestforhimorherself.

22.Ifeelthatmystudentwantstoattendtheuniversity.

23.Mystudentwillliveindependentofourfamilyaftergraduation.

24.Mystudentwillhavemeaningfulemploymentaftergraduation.

25.PersonCenteredPlanningwillhelpmystudentachievetheirgoals.

23Revised2-1-17

ScopeofServices

TheBridgeProgramisdesignedtoaddresstheuniqueneedsofstudentswithAutismSpectrumDisorder

ACADEMICS

ParticipantsintheBridgeDiplomaprogramatNichollsStateUniversityareenrolledthroughthe

traditionaladmissionsprocessasarealldegreeseekingstudents.TheBridgeDegreeprogramprovides

academicsupportservices.

HEALTHSERVICES

BridgestudentshaveaccesstocampusStudentHealthCenterservices.Theseservicesareforimmediate

firstaid/onsetcareonly.Bridgestudentsneedtomakeothermedicalarrangementsforlongtermcare

issues.Likewise,counselingandpsychologicalservicesprovidedbytheStudentServicesarealsofor

immediateemergencyinterventionsonly.Studentswithpre-existing/ongoingconcernsshouldmakethe

necessaryarrangementsfortheseknownissues.Bridgedoesnotendorseanyphysicianorcounselor

andthereforedoesnotmakereferrals.AspartoftheCollegeofEducation,individualandgroup

counselingservicesmaybeavailabletoBridgestudents.Theseservicesareprovidedbygraduatelevel

counselingstudentssupervisedbyaPh.D.instructor.OnceagainBridgedoesnotendorsetheseservices

andparticipationisoptional.

CODEOFCONDUCT

AllBridgestudentswillbeexpectedtoabidebythestudentcodeofconductasoutlined,

http://www.nicholls.edu/sja/files/2015/06/Code-of-Student-Conduct-Handbook.pdf.Bridgestudents

willfollowpoliciesofthejudicialsystemandtherecommendationsoftheVicePresidentofStudent

AffairsaswellastheBridgeAccountabilityPolicy.Anyresultingdisciplinaryactionwillfollowin

accordancewithNichollsStateand/orBridgepolicies.Thesepoliciesincludepermanentortemporary

expulsionofastudent.Parents/guardianswillneedtoacknowledgethattheywillbeactivemembersin

holdingtheirstudentaccountablefortheiractions.

PARENTS/GUARDIANS

ParentalinvolvementiscrucialforstudentsuccessintheBridgeProgram.Parentswillbeincorporatedin

manyimportantdecisionsthattheirstudentmaymakethroughBridgeIndividualPlanningMeetings.

24Revised2-1-17

However,theremaybetimesthatBridgeisboundbyconfidentialityorjudicialrulings,andmaybe

unabletoshareinformationaboutthestudentwithouthis/herpermission.TheBridgeProgramgoalis

tosupportstudentsinbecomingindependentadults,capableofself-advocacyandself-determination.

Parentsmaynotalwaysagreewiththedecisionsthattheirstudentsmake,butshouldmaintaina

positiveandopenrelationshipwithallparties.

________________________________________________________________________

Applicant’sNamePrinted Applicant’sSignature Date

___________________________

Parent/GuardianSignature

bridge to independence- diploma program … to independence- diploma program admission procedure ......

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