All 4 Autism Intake Form

Thank you for your interest in All 4 Autism.

Your input helps us locate services and support in our area that you are seeking. Please provide as much information and detail as possible, so that we will have the background we need to find appropriate resources. The more information we have, the more help we can provide.

Parent/Caregiver Information:

First Name *

Last Name *

Age *

Gender *

Email Address *

Daytime Phone *

Address 1 *

City *

State *

Zip Code *

Would you like to receive emails about events and news for All 4 Autism and our Autism Resource Center? *

Child's Information:

First Name *

Last Name *

Age *

Gender *

Does the child live with you? *

Does the child have a formal diagnosis? *

If yes, what is diagnosis? Please list where and when the child was tested.

What is the name and location of the child's Pediatrician? Has the child's Pediatrician performed any screenings for autism? *

Does the child have any siblings? Do any of the siblings have an ASD diagnosis? *

Does the child receive Medicaid/TEFRA? *

Does child have a case worker? If yes, what agency provided the case worker? *

Does child receive ABA services? If yes, what agency provides the ABA services? *

What are the child's favorite activities? *

What frightens or upsets the child? Any phobias or obsessive behavior?

What does the child do when he/she becomes frightened or upset?

Is the child verbally aggressive or destructive at times? If so, please describe the circumstances: *

How does the child react to changes in his or her environment? *

Does the child have a history of physical aggression or self-injurious behavior? If so, please describe circumstances, frequency and how long since you have seen this behavior. *

Does the child attend school or a day program? (Please share name of school/program, the hours he/she attends and if he/she attends with a shadow.) *

Does your child have an IEP or 504? Please indicate below: *

Does the child have any health, hygiene, or dietary issues? If yes, please give details: *

Is the child verbal? *

Can the child feed him/herself? *

Does the child have a tendency to wander? *

Is the child toilet trained? *

Is the child currently receiving any services? If yes, list below: *

What services or resources would most benefit the child, or your family? *

How can we help you?

How did you hear about All 4 Autism? *

If you would like to schedule an appointment with a Family Service Consultant, please select an available date and time below: (This consultation will be held over the phone, or at our Resource Center. You will receive an email confirmation with meeting details.)