Enrollment Application

Step 1 of 7

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Personal Information

Child's Name(Required)

Child's Date Of Birth(Required)

MM slash DD slash YYYY

Parent(s)/Guardian Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1 Phone Number(Required)

Parent 1 Email(Required)

Parent 2 Phone Number(Required)

Parent 2 Email(Required)

Where did your child receive a medical diagnosis of Autism Spectrum Disorder?(Required)

Date of Evaluation/Name of Evaluator(Required)

Center location choice for services(Required)

Insurance Information

Primary Insurance Company(Required)

Policy Holder's Name(Required)

Relation To Child(Required)

Policy Holder's Date Of Birth(Required)

MM slash DD slash YYYY

Occupation/Employer(Required)

Enrollee ID/Group Number(Required)

Education Information

Skip to the next section if your child is not in school yet.

Name of School

Grade

Classroom Description

Most recent IEP/IFSP date

Additional Services

Pleas list any services your child currently receives. (i.e. speech, OT, etc.) Include provider name, types of service, duration of service, and frequency

Medical & Behavioral Health History

Please indicate if any of the following variables that could affect your child's treatment apply to your family (historically or currently). If yes, include brief explanation

If any of the above are marked please provide brief explanation.

How has your child's overall health been?(Required)

Has your child exhibited any sexualized behavior (i.e. removing clothes in public, touching others inappropriately, etc)? If so, please describe below(Required)

Please list your child's current medications (both prescription and over-the-counter) and the conditions being treated(Required)

Please describe your child's food and medication allergies, if any(Required)

Do you have any concerns regarding your child's development (i.e. speech/language, motor movements, eating/feeding problems, etc)?(Required)

What interests or excites your child, what are his strengths? what frustrates her?(Required)

What other information would you like us to know?

Emergency Contact Information: Name, Relation, Phone(Required)

Parent Questionnaire

Using a rating scale of 1-5 (5 being very important to you, 1 being the least important to you), rate the following areas of learning you want for your child.

Communication (using signs/pictures/speech to get wants and needs met.)(Required)