New Patient Contact Form

Fill out the form below, this is the first step in providing information regarding your child.

Parent / Guardian:
Email:
Phone:
Child's Name:
Child's Age:
Insurance Provider: Group Plan / Private Policy

Diagnosis (Check all that Apply)
Autism PDD-NOS Asperger Syndrome
Developmental Delay Down's Syndrome Speech Delay
ADD/ADHD Behavior Disorder No Diagnosis
Other

Services interested in: (Check all that Apply)
1:1 ABA Therapy Clinical Classroom Social Skills Training
Speech Therapy Occupational Therapy School Shadow
Other

Child's primary form of communication?
No Communication Speech Sign
PECS Using Gestures Other

How does the child communicate if they want something?
How does the child communicate if they DO NOT want something?
Does your child display problematic behaviors (aggression, property destruction, tantrums, ect.)? How often do the behaviors occur?
Rarely Once a month Several times a month
Once a week Several times a week Once a day
Several times a day

Is your child currently enrolled in school?
Name of School:
Days Attended:
All / Half Day: All Day / Half Day

Please describe your child's skill levels in the following categories
Fine Motor
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Gross Motor Skills
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Receptive skills (Understanding what is being said, following instruction, selecting items, ect.)
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Play Skills
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Social Interactions
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Self Help
Age appropriate
Slightly Delayed (6months behind)
Moderately Delayed (1 year behind)
Severely Delayed (more than one year behind)

Is your child currently receiving other services? If so, what type and with whom?
1:1 ABA therapy:
Social Skills Training:
Speech Therapy:
Occupational Therapy:
School Shadow:
Physical Therapy:
Other:

Does your child have any other Medical issues?
Do you have transportation for your child 5 days a week?
Yes / No

Comments:
 
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