| Intake Form |
THE AUTISM CENTRE OF CANADA Please Let Us Know About Your Child Child's Name:__________________________ Age:_____ Sex:_____ Parent(s)/Guardian Name(s)________________________________ Address:________________________________ City:____________ Province:_________ Postal Code:__________ Home Phone:____ _____ _____Work Phone:_____ _____ _____ Best Time To Call You:_________ am ___________ pm Give the Brief History of Your Child: Pre-natal:____________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Post-natal:____________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ Family History:_________________________________________ _____________________________________________________ _____________________________________________________ What is the Diagnosis of Your Child? (Circle the appropriate) Autism Asperger CHDIS* PDD-NOS* Rett's PDA* Other
Who Diagnosed Your Child?(Circle the appropriate) Psychologist Psychiatrist Paediatrician Family Physician Other
Have you done or doing any therapy/program? ______________________________________________________ ______________________________________________________ What are the challenges you faced since your child is being diagnosed? ______________________________________________________ ______________________________________________________ ______________________________________________________ What Kind(s) of Help you are looking from The Autism Centre of Canada? Biological Intervention One-on-One Therapy Family Support Other (e.g. Sensory Integration, PECS etc.)
Any Other Information you would like to Add: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ *CHID=Childhood Disintegration Syndrome *PDD-NOS=Pervasive Developmental Disorder-Not Otherwise Specified *PDA=Pathological Demand Avoidance Syndrome Thanks for the info Copy & Paste this form into MS Word and then send as an attachment to e-mail info@autismcentreofcanada.org or Mail to: Autism Centre of Canada P.O. Box 452, Bothwell, ON N0P 1C0
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