CALIFORNIA ENROLLMENT APPLICATION
ABC - AUTISM BEHAVIOR CONSULTANTS

Date:

CHILD:
Child's Name:

Birthdate:   Age:   Male or Female:

MOTHER:
Mothers's Name:

Mothers's Occupation:

Work Phone:   Mobile Phone:

Email Address:

FATHER:
Father's Name:

Father's Occupation:

Work Phone:   Mobile Phone:

Email Address:

HOME INFO:
Home Address:

City:    State:    Zip:

Home Phone:   Fax:

Preferred method of contact:
i.e. home phone, mom's mobile phone, dad's office

SIBLING(S):
Name:    Age:

Name:    Age:

Name:    Age:

CHILD'S INFORMATION:
Current Diagnosis:

Diagnosed by:

Date Diagnosed:    Age of Diagnosis:

Pediatrician:

Immunologist:

Speech Pathologist:

Occupational Therapist

School District:

Regional Center Case Worker Name and Phone #:

Other:

Has your child received prior treatment:
yes no

If yes, please explain type, duration and by whom::

Is your child currently receiving DTT services?:
yes no

If yes, please state by whom:

Do you have funding for DTT?:
yes no

If yes, please detail source and how many hours:

Do you need an assessment to obtain funding?:
yes no

If yes, when will you need it by?:

How many therapy hours are you requesting per week: