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How to apply for an ASF grant in Walworth County

Autism Support Fund

Visit the Mercy Foundation website, MercyHealthSystem.org/Foundation, to download the ASF Grant 2013 application and instructions.

Helping local children who live with autism

Additional dates grant applications will be accepted: April 1-30, 2013 with notifications by June 30, 2013 July 1-31, 2013 with notifications by September 30, 2013 October 1-31, 2013 with notifications

by December 31, 2013 For more information about the application process, please contact Jennifer Johns at Mercy Foundation at (608) 755-8821.

How to apply for social skills classes in Rock County Social skills classes are offered in six-week sessions. Based on funding availability, registration may be reduced on a first come first serve basis, with priority given to families who did not recently access reduced rates.

For more information about registering for social skills classes, call Mercy Options Autism program at (608) 756-5555 x8313 or agoike@mhsjvl.org.

MERCY FOUNDATION

MercyHealthSystem.org

MERCY FOUNDATION

Autism spectrum disorder Autism spectrum disorder (ASD) is a complex neurobiological disorder that affects a child’s ability to effectively learn, socialize and communicate. Children with an ASD often struggle with making friends, adapting to daily activities, and managing their own behavior.

Approximately 1% of American children aged 3 to 17 has an autism spectrum disorder.

Children with autism can benefit from in-home treatment and various therapies that are often covered by insurance and/or government programs. However, many of these children require additional resources, classes and equipment for which there is very limited outside funding. That’s how Mercy Foundation’s Autism Support Fund (ASF) can help.

ASF: Who it helps, how it helps

How ASF is funded

For a family with a child with an ASD, the cost of additional resources, classes and equipment can be staggering—even overwhelming. Recognizing the fact that many of these children do not receive the comprehensive services they need, Mercy Foundation started its Autism Support Fund (ASF) in 2012.

In early 2012, Mercy Foundation recognized a huge hole in funding options for families that have a child with an autism spectrum disorder. In response, it formed the Autism Support Fund (ASF) with the hope that it could ease the financial pain so many families experience in treating their child with autism.

The Autism Support Fund makes financial resources available to families for things such as: • Social skills classes • Sensory equipment • Safety equipment • Respite care • Therapeutic materials

Mercy Foundation also raises ASF funds through other events.

All families in Rock and Walworth counties with children with an ASD are encouraged to contact us for more information. You do not need to be a Mercy Options Behavioral Health Services client or have a Mercy doctor as your primary health care provider to qualify.

All proceeds the ASF receives are directly used to help families of a child with autism. All administrative and overhead costs to support and manage the ASF are absorbed by the Mercy Foundation.

2013 ASF Grant Application Instructions and Form Date: Full name of person completing application: Address (Must be a Walworth County resident): Phone: Email: What school district does the recipient attend?

Recipient’s name:

Age of recipient*:

Diagnosis of recipient*: *See instructions for details Number of children in household: Have you received ASF funds before? ❑ Yes ❑ No Brief description of how the ASF funds will be used:

Amount of request:

Description of item:

Vendor:

How will these funds assist the recipient’s treatment plan/growth/development or promote the recipient’s independence or life skills?

Explain your financial need**:

**Please include verification of household income; see instructions.

Application Instructions • To request ASF funding, please complete the application form.

• *Age of the recipient must be between 2 and 21 years old.

• *Recipient’s diagnosis must be an autism spectrum disorder (ASD).

Please provide documentation from a licensed psychologist or behavioral health professional who has completed a comprehensive evaluation.

• Services/programs/equipment you are applying for must be related to the evidence-based treatment of an autism spectrum disorder.

Examples: Tools/equipment specific for ASD; respite services; social skills classes.

• You may submit one (1) application per quarter, (1) requested item per application, for a maximum of $500 per year. Checks will be written to the vendor.

• Applications must be submitted via email, fax or mail to: Email: jljohns@mhsjvl.org Fax: (608) 741-6923 Mail: Mercy Foundation, c/o Jennifer Johns, 903 Mineral Point Ave, Janesville, WI 53548 • You will receive confirmation that your application has been received.

• Applications will only be considered if the application is fully completed.

Grants will only be accepted quarterly: January 1 - 31 April 1 - 30 July 1 - 31 October 1 - 31

1st quarter notified at the end of March 2nd quarter notified at the end of June 3rd quarter notified at the end of September 4th quarter notified at the end of December

*Applicants must present documentation of a verified diagnosis, according to the criteria set forth by the Ins 3.36, Wis. Adm. Code.

A verified diagnosis of autism spectrum disorder must be made by a provider skilled in testing and in using empirically validated tools specific for autism spectrum disorders. In addition, the diagnosis must provide evidence that the patient meets the criteria for autism spectrum disorder in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Further, the assessment should include both a standardized parent interview regarding current concerns and behavioral history as well as direct, structured observation of social and communicative behavior and play. The diagnostic evaluation should also assess those factors that are not specific to an autism spectrum disorder, including degree of language impairment, cognitive functioning, and the presence of nonspecific behavioral disorders.

**In order to assess your financial situation, you must complete the application in its entirety).

You must also include: • Copies of the most recent income information for each person in the household including pay stubs, Social Security, unemployment, retirement, pensions, etc.