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Adult Day Program

ELIGIBILITY SCREENING — Lola’s Adult and Youth Programs

Please complete this quick screening to determine whether our group-based respite program is a suitable fit.
Your answers help us ensure safety, comfort, and appropriate staffing for all participants.

Name

This field is for validation purposes and should be left unchanged.

1. Mobility & Group Movement

How does your family member move around independently in a group setting?(Required)

Walks independently indoors and outdoors

Walks with occasional verbal prompts

Requires help to walk (someone holding their arm or guiding them)

Uses a mobility device (walker, wheelchair, stroller)

Cannot walk independently indoors or outdoors

2. Safety & Supervision

In the past 12 months, has your family member attempted to leave a supervised indoor or outdoor space without permission?(Required)

Yes, more than once

Yes, once

Unsure

Does your family member require 1:1 support in community or group settings to stay safe?(Required)

Yes, always

Yes, occasionally

3. Behavior in Group Settings

In the last 6 months, which of the following behaviours has occurred?(Required)

(Select all that apply)

Hitting, kicking, biting, or physical aggression toward others

Self-injury

Yelling or screaming at others

Throwing objects

None of the above

4. Regulation & Support Needs

When your family member becomes upset, what level of support do they typically need?(Required)

Calms independently with space

Calms with verbal reassurance

Calms with hands-on help

Requires physical restraint

Does not experience escalations

5. Group Program Readiness

Has your family member successfully participated in group programs without needing 1:1 staffing?(Required)

Yes

Sometimes

We have never tried

Disclaimer

Completing this eligibility screening does not guarantee acceptance into Lola’s Adult and Youth programs.
All information provided must be accurate and truthful.
Lola’s reserves the right to decline or terminate services at any time if inaccurate or misleading information is discovered, or if a participant’s support needs exceed what our group-based program can safely provide.

Contact Us

Lola’s Roundtable
69 Talbot St N
Essex, ON N8M 1A2

519-999-8617

Payment Methods

All prices are listed in Canadian dollars.

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