The Severe Behavior Program at Children's Specialized Hospital -- Rutgers University Center for Autism Research, Education, and Services (CSH-RUCARES) provides intensive and highly specialized services to children and adolescents with autism spectrum disorder who frequently engage in destructive behaviors such as aggression, self-injury, and property destruction that pose a risk to self, others, or the environment and cannot be safely and effectively treated in a less intensive program and/or with medication. Child's First and Last Name* must provide value
Caregiver's First and Last Name* must provide value
Caregiver's Email Address* must provide value
Caregiver's Phone Number* must provide value
May we text this phone number as part of follow-up (e.g., reminders to complete intake packet)? Yes
No
Answering "No" will not affect your child's eligibility for our clinical program.
What is your preferred mode of communication?* must provide value
Email Text message Telephone call
Are you interested in being contacted regarding research opportunities that may be relevant to your child (e.g., evaluation of a new behavioral therapy or drug trial)? Yes
No
Answering "No" will not affect your child's eligibility for our clinical program.
Some research studies evaluate sibling risk and interactions. If you answered "Yes" to being contacted about research, please indicate whether your child has any siblings and, if so, their ages. Some studies evaluate newborn behavior; if the mother of the referred child is expecting, please indicate.
Please confirm that you can provide transportation for your child to and from our clinic in Somerset, NJ.* must provide value
Yes
No
Does your child have a diagnosis of autism?* must provide value
Yes
No
Please provide your insurance carrier (e.g., Horizon BCBS) and the plan type or name (e.g., OMNIA plan).* must provide value
Which of the following behaviors does your child engage in? (Check all that apply and see examples in parentheses)* must provide value
Aggression (hitting, kicking, etc. others)
Property destruction (breaking, ripping, etc. items)
Self-injury (hitting, biting, hurting themselves)
Elopement (running away, wandering)
Pica (consuming inedible objects)
Risky behavior (touching hot items, consuming hazardous materials)
Oppositional behavior (noncompliance)
None of the above
If you have any images (e.g., photos of tissue/property damage), documents (e.g., copy of law-enforcement report) , or short videos (e.g., 1-min clip of your child's problem behavior) that would highlight the severity of your child's problem behavior, please upload those files here.
Would your child be able to attend one or both of our intensive behavioral programs? (Check all that apply)* must provide value
Half Day (3 hours per day [e.g., 9am-12pm, 1pm-4 pm], 5 days a week)
Full Day (6 hours per day [e.g., 9am-3pm], 5 days a week)
None of the above
Can you provide or arrange for consistent transportation to our clinic in Somerset (888 Easton Ave, Somerset, NJ) Monday through Friday?* must provide value
Yes
No
Has your child received at least 3 months of outpatient therapy conducted by a behavior analyst, psychologist, or other professional that focused on treatment of the above problem behavior (this can include outpatient caregiver training programs)?* must provide value
Yes
No
Has your child had at least 3 months of medication intervention for the above behavior problems OR has your physician/developmental pediatrician recommended intensive behavioral intervention in place of medication treatment?* must provide value
Yes
No
Based upon your selections, your child may engage in severe problem behavior that warrants admission to our clinic but does not meet one or both of the following: You indicated that you are unable to provide, or arrange for, regular transportation to our clinic in Somerset. You have indicated that your child would be unable to attend clinic for at least 3 hours per day, 5 days a week. We understand that this appointment duration can be challenging for scheduling or conflict with other services and requirements (e.g., school). However, we have found that this treatment dose is important for making meaningful progress for severe problem behavior. Based upon your selections, your child appears to meet the criteria for admission to our clinic. The next step in the admission process is for you to complete an intake packet that provides more information about your child and their behavioral concerns and developmental history.
If you would prefer to receive the intake packet via email, please check this box and we will attempt to send the packet electronically to the email you listed at the beginning of the screening form. Email preferred
As you wait to hear from us regarding your child's eligibility for our program, please see the attached "Resources for Caregivers" file for additional opportunities in your area for you or your child.
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