Autism Research Group

Autism Research Group
INFORMATION SHEET

Child's last name First M.I.	Date

Parent(s)' names	Child's Age

Street Address	Child's date of birth

City St. Zip	Home telephone

Child's diagnosis (if known)	Work telephone

Diagnosed by	Date of diagnosis

Is child a client of the Regional Center? yes no

How did you hear about the Program? (please check appropriate box)

caseworker parent in program school personnel a friend if so, whom?
Other (please specify)

Program History
Please list programs your child has attended. Include recent school programs and any behavioral programs.

Presenting Problem
What are the major concerns or problems you are currently experiencing with your child's behaviour or developmental skill levels? Please be specific.

Comments
Please list any additional comments you would like to add.

Additional Services
Please list any services you are interested in obtaining.