Asperger Manitoba Inc. Skills for Living Group Application

Asperger Manitoba Inc. will be receiving applications for adult skills-for-living groups on an ongoing basis.

Name: *

Address: *

Email address:

Telephone:

Gender: *

Age *

Select age range.

What is your primary diagnosis (e.g., Asperger Syndrome, high functioning autism, PDD-NOS, NLD)? *

How did you receive this diagnosis? *

Do you have any other diagnosed conditions? If so, please specify.

Do you receive any funded supports such as Community Mental Health, Community Living, Vocational Rehab, or others? If so, please describe.

Do you attend counselling or other support groups regularly? If so, please describe the group.

Are you comfortable participating in the group and interview on your own (e.g. without a support worker or parent)? *

Briefly describe why you would benefit from a social skills group. *

Would you be able to arrange transportation for yourself to the group meetings? *