Free Listing for Special Education/ Special Needs related services in upcoming Jewish Press magazine
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tell a friendThere are 10 possible sections below to fill out. Please fill out all areas that apply. Much of the information is setup as checkboxes. You can type in Y for Yes for that.
To avoid errors please email the filled in word document. Email to resources@buildingblocksmagazine.com . You can also fax it to 347-342-3152.
They are:
Contact Information
Early Intervention approved programs (Ages birth to 3) __
CPSE Schools or Centers (Ages 3-5) __
CSE Schools or Centers (Ages 5-21) __
Therapy and Evaluation Services __
Camps __
Day Habilitation __
Residences __
OPWDD and other programs __
Advocacy __
Other __
…………………………………………………………………………………………….
1) Contact Information
Name of organization, school or camp: ___________________________________
Address: ________________________________________________________
Phone: _____________________
Website: ______________________
(These next 2 questions are for follow up purposes only)
Name of person completing this form_______________________
Contact#_________________
…………………………………………………………………………………………….
2) Early Intervention Approved Programs
Home Based __ Center Based __
ABA ___Floor Time __ Sensory Integration __ MEDEK __
Other (Please specify) ___________
Other services offered such as family counseling, play therapy, music therapy, parent support groups etc…___________________________________________________
……………………………………………………………………………………………..
3) CPSE Schools or Centers
Home Based ___ Center Based ___ Will send providers to private schools ___
State Approved ___ Privately Funded __
Population Served (Please check those that apply:)
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___
ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Please check the following services provided:
SEIT ___ OT ___ PT ___ Speech ___ Play therapy/counseling ___
What special training or services do you offer children?
ABA ___ Floor Time ___ Sensory Integration ___ MEDEK ___
Other (Please specify) ________
Bilingual Staff If yes list language(s)?_______________________________
………………………………………………………………………………………………
4) Schools – School Age (CSE 5-21)
State Approved ___ Privately Funded ___
Population Served
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___
ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Ages Served _________ Boys ___ Girls ___ Separate classes ___ Mixed classes ___
School Hours: _______________ Handicap Accessible ___
Bilingual Staff If yes list language(s)?_______________________________
Services offered:
ABA ___ Floor Time ___ Pre-Vocational ___ Other (Please specify) ____________
Are therapies provided on site? ___ List therapies provided _______________________________
Breakfast provided ___ Lunch provided ___ Meals Kosher ___
Is transportation provided? ___
Is transportation private ___ or through the Department of Education ___? ………………………………………………………………………………………..
5) Therapy and Evaluation Services
Home Based ___ Center Based ___ Will send providers to private schools ___
Ages Served ________________
Accept RSA’s ___ Accept P3s ___ Accept Insurance ___
If yes, please list which insurances are accepted: ____________________________
OT ___ PT ___ Speech/Language ___ Special Ed ___
Do you conduct private evaluations? ___ Other Services ______________________
Handicap Accessible ___ Bilingual (list languages)_____________
Population Served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___
ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Services offered:
ABA ___ Floor Time ___ Sensory Integration ___ MEDEK ___
Other (Please specify) __________________________________________
………………………………………………………………………………………..
6) Camps and End of Summer Programs
Duration, # of Weeks _______ Day camp ___ Sleep away camp ___
Location of Camp: ____________________________________________
Ages Served: ______________ Male ___ Female ___ Separate ___ Mixed ___
Population served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Speech & Language impaired ___ Learning Disabled ___
ADD/ ADHD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Is special education and related services (therapy) provided on site? _____________
Handicap Accessible ___ Kosher food provided ____ NY State Approved ___
Do you accept children who are not toilet trained? ______
………………………………………………………………………………………..
7) Day Habilitation
Ages ___ Group Size ____ Male ___ Female ___ Separate ___ Mixed ___
Center Based ___ DayHab Without Walls ___ Program hours: __________
Are vocational services offered? _____
Population:
_____Mild to moderate developmental delays
_____ Moderate to severe developmental delays
Handicap Accessible ___ Kosher food provided ___ Transportation provided ___
………………………………………………………………………………………..
8) Residential opportunities:
Ages Served _________ Male ___ Female ___
Population Served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___
Do you have accommodations or specialization to serve the following populations?: Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
IRA’s ___ Supportive Apartments ___
………………………………………………………………………………………..
9) OPWDD and other programs
A) Medicaid Waiver __
B) Family support services __
Does your agency offer support groups/services to parents? ____ Siblings? ___
C) Respite ___
D) Overnight respite ___
E) Sunday Program ___
Ages served______ Male ___ Female ___ Separate ___ Mixed ___
Population served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Handicap accessible? ____ Provide transportation? _____
Is there a fee for your program? _____ Provide kosher food? _____
Do you take children who are not toilet trained? ______
F) After School Program ___
Location: _______________________________________________
How may days a week? __________ Ages served______
Male ___ Female ___ Separate ___ Mixed ___
Population served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped ___
Handicap accessible? ____ Provide transportation? _____
Is there a fee for your program? _____ Provide kosher food?_____
Do you take children who are not toilet trained? ______
G) Recreation ___
Ages served __________ Male ___ Female ___ Separate ___ Mixed ___
Population served:
Mild developmental delays ___ Moderate to severe developmental delays ___ Autism/PDD ___ Emotionally disturbed ___ Hearing impaired ___
Visually impaired ___ Multiply handicapped __
How often does your program take place? _____________________________
Where does your program take place? _________________________________
Handicap accessible? ____ Provide transportation? _____
Is there a fee for your program? _____ Provide kosher food? ____________
Do you take children who are not toilet trained? ______
Is your program open to families (parents and siblings) as well as special children_____________________
………………………………………………………………………………………..
10) Advocacy
Region(s) served______________________
Do you provide assistance/representation to parents at:
IEP Meetings ___ Impartial Hearings ___ Appeals ___
………………………………………………………………………………………..
Other Services
For services that don’t fit in categories above. Geared towards agencies and organizations that don’t apply at all to above categories.
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