Autism Research Group
INFORMATION SHEET


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 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.

 
 
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