Enrollment Application | Behavior Analysts of West Michigan

You will need to provide the following outside of this application:

– Report/evaluation confirming diagnosis of Autism Spectrum Disorder (ASD)– Most recent physical examination (must be completed by PCP within the past 12 months)– Any other recent evaluations the child has had completed (i.e. school, speech, OT, neurological, etc.)– An up-to-date record of all immunizations the child has had– If insurance is involved, pre-authorization is required prior to any evaluation, therapy, or any other service being provided– In-take interview– VB-MAPP completed by BAWMI staff– Meeting with BCBA to discuss goals and program plan– Arrangement of therapy scheduleThe following is required so that we can best meet the physical, intellectual, behavioral, and emotional needs of your child and family. The information provided will remain confidential in accordance with HIPPA laws.

Personal Information

Child's Name & DOB *

Parent(s)/Guardian Name *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

When did your child receive a medical diagnosis of Autism Spectrum Disorder? *

Date of Evaluation/Name of Evaluator *

Center location choice for services: *

Insurance Information

Primary Insurance Company *

Carrier/DOB/Relation: *

Occupation/Employer *

Enrollee ID/Group Number *

Educational Information

If your child is not in school yet, skip to the next section.

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.

Medical conditions (i.e. epilepsy, diabetes, etc)Behavioral health conditions (i.e. depression, ADHD, etc)Legal issues that would affect treatment (i.e. persons child is allowed to leave with, etc)Spiritual/cultural values that would affect treatment (i.e. dietary, medical treatment, religious holidays, etc)

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

How has your child's overall health been? *

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

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

Please describe your child's food and medication allergies, if any: *

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

What interests or excites your child, what are his strengths? what frustrates her? *

What other information would you like us to know?

Emergency Contact Information: Name, Relation, Phone *

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.

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

2. Social Skills (approach others, say hi to others, sharing experiences with others) *

3. Play Skills (plays appropriately with toys, plays with a variety of toys) *

4. Behavior (decrease screaming, crying, hitting, kicking, biting, etc) *

5. Behavior (decrease unusual behaviors like tapping items, spinning toys, licking things, etc) *

6. Personal care (dress and undress self, brush teeth, wash hands, etc) *

7. Toileting (be independent and self-initiating using the toilet for urinating and bm’s) *

8. Eating (eat with utensils, eat a variety of foods, drink from a cup) *

File Upload

FRONT of Insurance Card

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BACK of Insurance Card

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Diagnosis Report

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