Client Registration Form DOB Age Gender * Male Female Transgender Other Prefer not to say Mother's Information DOB Home Phone Cell Phone * Work Phone Email * Occupation Employer Insurance Carrier Father's Information DOB Home Phone Cell Phone * Work Phone Email * Occupation Employer Insurance Carrier Siblings/Household Members (Other than parent/guardian) DOB Relationship to Child DOB Relationship to Child DOB Relationship to Child Emergency Contact Information Phone Relationship to Child Phone Relationship to Child Other Services Provided (Speech/PT/OT, etc.) Name of Provider Services Provided/Times per week Name of Provider Services Provided/Times per week Name of Provider Services Provided/Times per week Diagnosis Primary Diagnosis 1 Diagnosis Date(s) Diagnosing Professional Primary Diagnosis 2 Diagnosis Date(s) Diagnosing Professional Primary Diagnosis 3 Diagnosis Date(s) Diagnosing Professional Medical Conditions (if any) Allergies Diagnosing Professional Special Diet Information Current Medications (list them) Child's Educational Background School Grade Please list any other important information you would like us to know about your child. Informed Consent DOB Do you confirm this information is correct? * I agree to have my child evaluated/treated by Autism Behavior Support, LLC. I understand that these services are based on an Applied Behavior Analysis (ABA) model and will be provided by a professional trained in ABA. I understand that state laws may require that confidentiality be broken under certain circumstances, specifically, if I am judged by the behavior analyst to be of danger to myself and/or others, gravely disabled, or if there is suspected child abuse. I also understand that Autism Behavior Support, LLC specializes in the evaluation and treatment of problem behaviors as well as skill acquisition, and if Autism Behavior Support, LLC is unable to meet my particular needs, I will be referred to an appropriate agency or individual. Services: Autism Behavior Support implements the Applied Behavior Analysis for its services. A variety of techniques are integrated and utilized during treatment. You will be encouraged to practice various skills introduced in sessions. A treatment plan with specific goals will be explored and updated according to treatment plan schedules. Recommendations for additional treatment and/or intensive treatment may be made, if needed. When a client is a minor under the age of 14, parent involvement is required during all visits with the client. Information will be limited to accommodate confidentiality with children of all ages. Family involvement is an important part of treatment. Children under the age of 18 will require a parent’s signature (or legal guardian) to receive any form of treatment.