Intake Form

Personal Information

Child's Name*

Date of Birth*

Diagnosis*

Gender*

Male
Female

Allergies*

Grade in School/Preschool*

Parent/Guardian's Name*

Occupation*

Phone (home)

Phone (mobile)

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian's name

Occupation

Phone (home)

Phone (mobile)

Email

Address (if different from above)

Street Address Address Line 2 City State ZIP Code

Primary Health Insurance Information

Subscriber's Name

Subscriber's date of birth

Insurance Company

Identification Number

Group Number

Seconday Health Insurance Information (if applicable)

Subscriber's Name

Subscriber's date of birth

Insurance Company

Identification Number

Group Number

Authorize release of Information

I authorize release of information and benefits assignment from my insurance company.

Referral Information

Referral from a friend

Referral from school

Referral from pediatrician

Referral given at diagnosis

Referral from the ARC

Referral from another provider

Google

Other

Who diagnosed your child with autism? What was the date of diagnosis?

Description of Needs

Please list any specific challenging behaviors your child demonstrates.

What is your child’s primary form and current level of communication?

What is your child’s current level of independence with toileting and feeding?

Services and Scheduling

What type of services are you seeking at South Shore Autism Center? (check all that apply)

Center Based: Use ABA principles to address communication, social skills, play skills, classroom readiness, and challenging behaviors through supported social interactions with peers in leveled preschool classrooms as well as 1:1 therapy sessions as appropriate. Services run throughout the year, including school breaks and summer. Timing of services can be adjusted based on age of child, nap schedule, and other services they receive. In-home services may be recommended in addition to center-based services for children younger than age 3 as they transition to center-based services. Center-based services are available Monday - Friday 9:00-12:00 for morning sessions and/or 12:00-3:30 for afternoon sessions, appropriate for children 18 months - Kindergarten.
Social Skills Groups: Use ABA principles to address social skills such as conversation, turn-taking, sharing, following rules, and good sportsmanship during weekly activity-based group that may include typical peers. Children are placed in groups with peers of similar ages. Typically occur Monday - Thursday 4:00-6:00 pm, appropriate for ages 5-12.
Bridge Camps: For clients who participate in Social Skills Group services. Use ABA principles to maintain skills and routine during school breaks, including February break week, April break week, and 2-3 weeks over summer. Camps are groups of similar age peers that engage in fun activities like board games and Legos as well as specials like yoga and art. May include integration with typical peers. Camps run Monday - Friday 9:00-3:00, appropriate for ages 5-12, must be a current Social Skills Group client.
Parent Training: For clients who participate in Center Based services and/or Social Skills Groups, parent training and generalization strategies are built into our treatment plans to address generalization of skills from center to home using ABA principles. Daytime and evening group parent trainings are offered monthly at the center to support and inform parents while also fostering friendships with each other. Additionally, individual parent training sessions are available at home and/or in the center. Parent training services can occur during the day, after school, and/or weekday evenings depending on availability of parents and staff, appropriate for all ages.
In Home: Use ABA principles to address communication, social skills, play skills, self-help skills, and challenging behaviors through naturalistic instruction in the home and community. Services run throughout the year, including school breaks and summer. Timing of services is based on age of child, nap schedule, and other services they receive. In home services are available Monday - Friday 9:00 am - early evening and are typically in two-hour sessions, appropriate for 18 months – 13 years.

Please list the days, times and locations your child is in daycare, preschool, full day school and/or with other service providers and is therefore unavailable for SSAC services.

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Personal Information

Primary Health Insurance Information

Seconday Health Insurance Information (if applicable)

Referral Information

Description of Needs

Services and Scheduling

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