Child’s Information

Parent / Guardian Information

ParentLegal Guardian

Medical Information

Insurance Information

Which insurance does your child have? *

HealthPartnersBlueCross Blue ShieldHennepin HealthUcareState Insurance (MA)Other

Developmental History

Has your child ever received therapy/interventions? *

YesNo

Challenges (check all that apply):

Speech delaysSocial challengesSensory sensitivitiesCommunication difficultiesAggressive / behavioral issuesSelf-regulation difficulties

Behavioral & Educational Information

IEP in place?

YesNo

Any challenging behaviours at school / home / community?

YesNo

Reason for Enrollment in Autism Clinic

Parent / Guardian Signature *

[signature* parent-signature]

I consent to my child’s enrollment and understand the clinic will use this information to provide services*.

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