Initial Client and Insurance Information Form (Fields marked with * are required.) Personal Information Childs Name* Date of Birth* Diagnosis* Gender MaleFemale Allergies* Grade in School/Preschool* Parent/Guardian's Name* Occupation* Phone (home)* Phone (mobile)* Your Email* Address Line 1* Address Line 2* City* State* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip/Postal Code* Primary Health Insurance Information Subscriber's Name* Subscriber's Date of Birth* Insurance Company* Identification Number* Group Number* Secondary Health Insurance Information (if applicable) Subscriber's Name* Subscriber's Date of Birth* Insurance Company* Identification Number* Group Number* I authorize the release of information and benefits assignment from my insurance company Parent 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 the diagnosis? 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. 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. Signature* By typing in your name below, you are approving everything on this form.
