Intake Form

Personal Information

Child's Name*

Date of Birth*

Diagnosis*

Gender*

Male
Female

Name of School/Preschool*

Grade in School/Preschool*

Names and Ages of Siblings

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.

Parent E-Signature

Date

Referral Information

How did you hear about South Shore Autism Center? Please fill in the blank with who referred you or how you heard about us.

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?

Do you have a copy of the diagnosis report?

Yes
No

If no, when do you expect it?

Description of Needs

Please describe any specific challenging behaviors your child demonstrates, such as kicking, throwing objects, tantrums, pushing others, etc.

How does your child communicate with you? Please give an example of how your child would let you know they wanted something.

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

Language and Communication Preferences

What language(s) other than English is/are spoken in your home?

Would you like written communication to be translated into another language?

Yes
No

If yes, please list the language(s) you would like us to use.

Would you like an interpreter for spoken communication?

Yes
No

If yes, please list the language(s) you would like us to use.

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. Includes some integration with typical peers. 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. 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.
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.
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. Children are placed in groups with peers of similar ages. Groups are held Monday - Thursday 4:00-6:00 pm, appropriate for ages 5-13.
Bridge Camps: For clients who are currently enrolled in Social Skills Group services. Use ABA principles to maintain skills and routine during breaks in school-based services. 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. Camps run Tuesday - Friday 9:00-noon, appropriate for ages 5-13, must be a current Social Skills Group client.
Parent Training: 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 SSAC clients.

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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