Introduction
Please complete the following information below to help us assess your agency’s interest in and capacity to implement a Cognitive Enhancement Therapy (CET) program for verbal adults with autism spectrum disorder.

CET was developed and studied at the University of Pittsburgh and shown to help improve neurocognitive and social cognitive difficulties in verbal adults with ASD and without intellectual disability. Common neurocognitive difficulties in ASD include difficulty with concentration, working memory and problem solving. Social cognitive challenges in ASD that are targeted by CET include areas such as perspective taking, social context appraisal, cognitive flexibility and foresightfulness.

CET is an 18-month cognitive remediation approach that integrates computer-assisted neurocognitive training conducted with pairs of participants and small social-cognitive group sessions of 6-8 participants to improve functioning in verbal adults with autism spectrum disorder without intellectual disability. A minimum of two (2) master’s-level therapists are required to provide CET, although it is recommended that agencies train more than the minimum number of required therapists. Clients receiving CET need to be able to commit to attending the program in-person for 3 hours per week (2 x 1.5 hour appointments).

General:
Agency Name:

Agency Address:

Your Name:

Your Title:

Your Phone Number:

Your Email Address:

How does your agency receive its funding for client services (select all that apply)?
 Fee for Service Block Grants Waiver Grants Other Unsure

Other Funding Source (if applicable):

Does your agency plan to bill for CET services (e.g., group and individual sessions; neurocognitive training)?
 Yes No Unsure

Client Population:
Adults with autism spectrum disorder who are appropriate for and most likely to benefit from Cognitive Enhancement Therapy include those who are verbal; have significant difficulty in cognition, social understanding and effective communication; have an IQ of 80 or above; are able to read and speak fluent English; and have the ability to focus and attend a group treatment for at least 90 minutes.

Estimated total number of adult clients, 18 years or older, with autism spectrum disorder served annually:

Estimated total number of adult clients, 18 years or older, with autism spectrum disorder served annually who are likely eligible to receive CET:

Estimated total number of potentially eligible adults with autism spectrum disorder who would be interested in participating in CET:

On a scale from 1-10 (10 being very interested and 1 showing no interest), what is your estimate of the degree of interest your ASD adult clients might have in participating in a program like CET?

Staff:
Therapists who are effective in delivering Cognitive Enhancement Therapy have at least two years of experience in working with adults with autism spectrum disorder; a master’s-level degree or higher in social work, psychology, counseling, nursing, or other helping profession; and are open-minded and comfortable with learning a new practice approach.

Estimated total number of therapists at the agency who serve adults with autism spectrum disorder in an outpatient setting:

Estimated total number of master's-level therapists at the agency with 2+ years experience in treating adults with autism spectrum disorders in an outpatient setting:

Estimated total number of therapists at the agency that the administration would support (e.g., provide release time for training and supervision) in learning and providing CET

Average caseload count for therapists at the agency -

Average:

Minimum:

Maximum:

Estimated total number of potentially eligible therapists at the agency who would be interested in learning to provide CET:

On a scale from 1-10 (10 being very interested and 1 showing no interest), what is your estimate of the degree of interest your therapists might have in receiving training to provide CET?

Facilities:
Total number of the agency’s private offices with computers available for CET neurocognitive training sessions and individual therapy sessions with ASD adult clients:

Total number of the agency’s private group/conference rooms available for CET social-cognitive group sessions with ASD adult clients: