Personal Information

Child's Name*

Date of Birth*

Diagnosis*

Gender*

Male
Female

What services are you seeking? (CHOOSE ONE - Center Based, In-Home or Counseling). All schedules will be based on clinical need, age of the child, nap schedule (if any), other services they receive, and insurance authorization/approval for desired services. All programs run on a consistent schedule throughout the year, including summers (closed for holidays and professional development)

Center Based: Use ABA principles to address communication, social skills, play skills, classroom readiness, and challenging behaviors through supported social interactions with peers in preschool-age classrooms. Center based services are available Monday - Friday up to 9:00-3:30 daily, appropriate for ages 18 months - 6 years/preK.ce
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 8:30 am - 3:00 pm and are typically in 2-3 hour sessions, appropriate for 18 months – 10 years.

If Center Services, select ONLY ONE center below*

Norwell
Quincy
West Bridgewater

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 NOTE - Services at our centers do not include naps.

Which Schedule Do You Prefer? (Center Based)*

Monday - Friday mornings only (9:00-12:00)
Monday - Friday afternoons only (12:00-2:00 under age 3-3½ or 12:00-3:30 over age 3-3½)
Monday - Friday 5 full days (9:00-2:00 under age 3-3½ or 9:00-3:30 over age 3-3½)
Mon, Wed, Fri 3 full days (9:00-2:00 under age 3-3½ or 9:00-3:30 over age 3-3½)
Tue and Thurs 2 full days (9:00-2:00 under age 3-3½ or 9:00-3:30 over age 3-3½)

Which Schedule Do You Prefer? (In Home)*

8:30-11:30 am
12:00-3:00 pm

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.

Days*

Mon, Wed, Fri (3 days)
Tue, Th (2 days)

Days*

Mon, Wed, Fri (3 days)
Tue, Th (2 days)

Days*

Mon, Wed, Fri (3 days)
Tue, Th (2 days)

Days*

Mon, Wed, Fri (3 days)
Tue, Th (2 days)

Please list any/all other recurring schedules for your child such as daycare, preschool, school, and/or services with other service providers (speech, OT, etc) when your child is therefore unavailable for SSAC services (provide days of the week and times of day for each).

Other Personal Information

Name of School/Preschool

Grade in School/Preschool

Names and Ages of Siblings

Parent/Guardian's Name*

Occupation*

Phone 1*

Phone 2

Email*

Address*

Street Address Address Line 2 City State ZIP Code

2nd 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

Secondary 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 us?*

If you are referred by a doctor, school or other provider, please let us know which one.

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

Do you have a copy of the diagnosis report?*

Yes
No

If no, when do you expect it?

Description of Needs

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

Please describe how your child typically plays alone. Also describe how your child plays with other children around his/her age.*

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

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

Language and Communication Preferences

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

Would you like an interpreter to review written communication?*

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.

Signature*

By typing in your name below, you are approving everything on this form.

Phone

This field is for validation purposes and should be left unchanged.

Intake Form

We are no longer accepting clients to our waitlist for social skills groups. Please check back at a later time.

Personal Information

Other Personal Information

Primary Health Insurance Information

Secondary Health Insurance Information (if applicable)

Referral Information

Description of Needs

Language and Communication Preferences

Norwell Autism Center

Quincy Autism Center

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