- Kwanga Therapy & Consulting

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Subject: Notice of Confidentiality for User Information

Dear Participant,

We would like to inform you that any information provided by you through our platform is treated with the utmost confidentiality. Your privacy is a priority for us, and we are committed to safeguarding the security and integrity of the data you share.

Our data protection measures include:

Secure Storage:
- All information is securely stored to prevent unauthorized access.
Limited Access:
- Access to your data is restricted to authorized personnel with a legitimate need.
Encryption:
- We use encryption protocols to secure data during transmission and storage.
Strict Privacy Policies:
- Our privacy policies outline how your information will be used and protected.
Compliance:
- We adhere to applicable data protection laws to ensure your rights and privacy are respected.

By using our services, you acknowledge and agree to the confidentiality measures outlined above. Should you have any concerns or questions regarding the handling of your information, please do not hesitate to reach out to our privacy team at enquiries@kwangatherapyandconsulting.com or +254 794 502692

Thank you for entrusting us with your information.

Sincerely,

Kwanga Therapy & Consulting

Name *

First

Last

Email *

Occupation

Availability for training for significant other

Who is available for training?

Client age group

How old is the client?

How did you hear about us?

Has the client received help for the concern before?

If you selected other, please elaborate

General Self-help skills

No independent self-help, but does not engage in challenging behaviors when others provide personal care

True
False

Requires verbal or physical prompts to complete most self-help tasks

True
False

Requires mostly verbal prompts, but will attempt approximations to several self-help tasks

True
False

Initiates some self-help tasks and usually attempts approximations, but still requires verbal prompting

True
False

Is motivated, initiates approximations for most skills, and generalizes, but may need verbal prompts or is independent

True
False

Toileting skills

Still wears a diaper, but demonstrates toilet training readiness (e.g., dry periods, sits still for 2 minutes, tries to remove soiled clothes)

True
False

Toilet training has begun, will occasionally urinate when seated on the toilet, but still wears a diaper

True
False

Daytime bladder trained, uses pull-ups, has occasional accidents, needs prompts and assistance to complete the toileting routine

True
False

Both bladder and bowel trained, but needs prompts and assistance to complete the toileting routine

True
False

Initiates or demands to use the bathroom and independently completes all steps of the toileting routine

True
False

Eating skills

Demonstrates some independent eating, but requires many physical prompts to eat, often a messy eater

True
False

Independently eats finger foods, but requires adult arrangement of food, verbal prompting, and clean up

True
False

Independently gets food from their lunchbox, eats finger food, but requires adult verbal prompting to eat

True
False

Independently uses a spoon, eats without prompts, makes a minimal mess, needs prompts to clean up

True
False

Independently gets food items, eats, and uses utensils, cleans up independently or with verbal prompts

True
False

Does the individual take more time to feed than would be reasonably expected for their age or past feeding history?

Does the individual feed orally or non-orally?

Orally
Non-orally

. Does the individual cough (no medical reason) routinely?

Does the individual have food left over in the mouth after a meal?

Does the individual cough, choke, clear throat or gag during or after (1-2 hrs) eating, drinking or tube feeding?

Does the individual lose food/formula from their mouth/nose during eating/tube feeding?

Does the individual’s voice or vocalizations sound different during or after a meal or tube feeding?

Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

Weight loss during the last 3 months

0 = weight loss greater than 3 kg (6.6 lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss

Mobility

0 = bed or chair bound
1 = able to get out of bed / chair but does not go out
2 = goes out

Has suffered psychological stress or acute disease in the past 3 months?

Neuropsychological problems?

0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems

Body Mass Index (BMI) (weight in kg) / (height in m2)

0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater

Works Independently on Tasks or Hobbies

Works independently on tasks for at least 30 seconds with no more than 1 prompt

True
False

Works independently on tasks for at least 1 minute with no more than 1 prompt

True
False

Works independently on tasks for at least 2 minutes without prompting

True
False

Works independently on tasks for at least 3 minutes without prompting

True
False

Works independently on tasks for at least 5 minutes without prompting

True
False

Works independently on tasks for at least 10 minutes without prompting

True
False

Sensory Defensiveness

No problems related to sensory stimuli

True
False

People begin to notice that sensitivity to various sensory stimuli is different from that of other individuals

True
False

Certain sensory stimulation may affect the individual, but the defensiveness is mild and does not usually interfere with other activities

True
False

Frequently reacts to specific sensory stimuli with escape behaviour such as hands over ears, closing eyes, or getting agitated

True
False

Consistently reacts to specific sensory stimuli with negative behaviour such as tantrums and aggression, presence of certain sensory stimuli competes with completion activities

True
False

Articulation Problems

Do people notice that the individual’s vocal behavior is different from others or not as expected for their age or sex ?

Most people can understand the individual's existing vocal behavior

True
False

Some difficulty pronouncing certain words, but usually can be understood, and articulation improves

True
False

Has difficulty being understood by strangers.

True
False

Very limited vocal skills and demonstrates a wide variety of articulation errors

True
False

Non-vocal, or has completely unintelligible speech, despite other elevated advanced skills.

True
False

Challenging Behaviours

Does not demonstrate any significant challenging behaviours

True
False

Engages in some minor challenging behaviours weekly, but recovery is quick

True
False

Emits a variety of challenging behaviours daily (e.g., crying, verbal refusal, falling to the floor)

True
False

Emits more severe challenging behaviour daily (e.g., tantrums, verbal abuse, throwing things, property destruction)

True
False

Often emits severe challenging behaviour that is a danger to themself or others (e.g., aggression, self injury)

True
False

Instructional Control (Escape and Avoidance of Instructional Demands)

Typically, cooperative with instructions and requests

True
False

Some of these will invoke minor non-compliant behaviour, but recovery is quick

True
False

Emits noncompliant behavior a few times a day, with minor tantrums/complaints, or other minor behaviors

True
False

Emits noncompliant behavior several times a day, with longer tantrums/complaints and more severe behaviors

True
False

Noncompliant behavior dominates the individual's day, challenging behaviours can be severe and dangerous

True
False

MATH

Names the numbers 1-5

True
False

Counts out 1-5 items from a larger set of items with 1 - 1 correspondence (e.g., give me 4 cars. Now give me 2 cars)

True
False

Identifies as a listener 8 different comparisons involving measurement (e.g., show me more or less, big or little, long or short, full or empty, loud or quiet)

True
False

Correctly matches a written number to a quantity and a quantity to a written number to the numbers 1-5 (e.g., matches number 3 to a picture of 3 trucks)

True
False

READING

Attends to a book or written text (for 75% of the time) when being read to or reads for more than 5 minutes.

True
False

Selects the correct uppercase letter from an array of 5 letters, for 10 different letters

True
False

Names 10 uppercase letters when shown

True
False

Reads their name

True
False

Matches 5 words to the corresponding pictures or items in an array of 5, and vice versa (e.g., matches the written word bird to a picture of a bird)

True
False

WRITING

Does the individual draw, copy letters and numbers, and independently write their own name

Imitates 5 different writing actions using a writing instrument and writing surface

True
False

Independently traces within 1/4 inch of the lines of 5 different geometrical shapes (e.g., circle, square, triangle, rectangle, star)

True
False

Copies 10 letters or numbers legibly

True
False

Legibly spells and writes their name without copying

True
False

Copies all 26 upper and lowercase letters legibly

True
False

Classroom Routines and Group Skills

Does the individual follow the daily routines in a classroom and appropriately participate in group activities, and respond in a group-teaching format?

Sits at a group snack or lunch table without challenging behavior for 3 minutes

True
False

Puts away personal items, lines up, and comes to a table with only 1 verbal prompt

True
False

Transitions between activities with no more than one gestural or verbal prompt

True
False

Sits in a small group for 5 minutes without disruptive behavior or attempting to leave the group

True
False

Sits in a small group for 10 minutes, attends to the speaker or material for 50% of the period, and responds to related queries.

True
False

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